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Nevin W Wilson, Mary Beth Hogan, Charles Bruce Harper, Kathy Peele, Sonia Budhecha, Vincent Loffredo, Vanessa WongUniversity of Nevada School of Medicine, Department of Pediatrics, Section of Allergy, Immunology and Pulmonology, Reno, NV, USABackground: Chronic cough in children is a common problem, and sinusitis is a common etiology. The diagnosis of sinusitis is often clinical, but confirmation is thought to require a CT scan due to the difficulty of interpreting a Water’s view sinus X-ray.Objectives: The purposes of the study were (1) to examine the frequency of an abnormal sinus X-ray in children with a chronic cough of more than 4 weeks duration; (2) to compare the interpretation of the sinus film between allergy/pulmonary clinicians and radiologists; and (3) to correlate symptoms with X-ray results.Methods: A chart review of 2- to 18-year-old patients with coughing exceeding 4 weeks was performed. Data was collected for patients who had received a Water’s view sinus film as part of their evaluation. Exam, X-ray results, and clinical outcomes were categorized and statistical analyses performed.Results: A total of 86 patients were included. Clinicians found that 65% of the children had positive Water’s view films, compared with the radiologist’s reading of 62% (non significant). Significant associations between post-tussive emesis (P = 0.01) and purulence (P = 0.03) were noted with a positive film. Positive sinus X-ray was highly associated with all findings except wheeze when present together (P < 0.001).Conclusions: Sinus abnormalities on X-ray are associated with prolonged cough in 65% of children. The Water’s view sinus film is a clinically useful screening tool for clinicians in the workup of chronic cough. Certain physical findings and clinical complaints, when present concurrently, correlate with the X-ray results.Keywords: Water’s view sinus X-ray, asthma, allergic rhinitis, radiologist, post-tussive emesis, wheezing

A model of children's attitudes toward their epilepsy was tested in 173 children (9-14 years) with epilepsy and their parents. Predictor variables tested were child characteristics, family mastery, child worry, child self-efficacy for seizure management, child psychosocial care needs, and seizure variables. Data were analyzed using structural equation modeling, leading to a revised model in which less child worry, greater family mastery, and greater child seizure self-efficacy were directly related to more child positive attitudes. Discussion focuses on potential targets for psychosocial interventions aimed at improving attitudes toward epilepsy. [ABSTRACT FROM AUTHOR]

The main purpose of this study was to evaluate the role of child behavior problems, parenting distress, and child routines in relation to children's adherence to daily medication in pediatric asthma. Participants included 45 asthmatic children and their families. Assessment included questionnaires, a medication dose-count monitor, and a brief telephone interview with the parent. Significant negative correlations were found between child care routines and both parenting distress and difficult child behavior. Medication adherence was significantly and positively correlated with both parental distress and difficult child behavior but was not significantly related to parent use of routines. [ABSTRACT FROM AUTHOR]

We investigated youth and parent knowledge of asthma using the Asthma Questionnaire (AQ), a newly developed measure that targets general asthma-related knowledge and knowledge of techniques often utilized to manage asthma symptoms. Participants included 46 youth with asthma and 126 parents of children with asthma. Also participating in the study was a comparison group consisting of 19 youth and 20 parents with no familial history of asthma. Results provided support for internal consistency and discriminant validity. Unlike knowledge measures previously published, the AQ is supported by its multi-informant versions, item format, and satisfactory initial psychometric properties. [ABSTRACT FROM AUTHOR]

We report the development of a Shiga toxin–producing Escherichia coli O157 gastrointestinal infection associated with hemolytic uremic syndrome in an allogenic stem cell transplant recipient with a history of gastrointestinal graft-vs-host disease receiving long-term immunosuppression.

Background: SARS-CoV-2 is known to manifest a robust innate immune response. However, little is known about inflammatory influences from maternal SARS-CoV-2 infection or maternal mRNA vaccination upon the fetus. In addition, it is unknown if Vitamin D deficiency influences fetal homeostasis or if an anti-inflammatory mechanism to the development of possible innate cytokines or acute phase reactants by the maternal/fetal dyad, in the form of cortisol elevations, occur. In addition, effects on Complete Blood Count (CBC) are not known., Objective: To evaluate the neonatal acute phase reactants and anti-inflammatory responses after maternal SARS-CoV-2 disease or mRNA vaccination., Methods: Samples and medical records reviews from mother/baby dyads ( n  = 97) were collected consecutively, and were categorized into 4 groups; no SARS-CoV-2 or vaccination exposure (Control), Vaccinated mothers, maternal SARS-CoV-2 disease positive/IgG titer positive fetal blood, and maternal SARS-CoV-2 positive/IgG titer negative fetal blood. SARS-CoV-2 IgG/IgM/IgA titers, CBC, CRP, ferritin, cortisol, and Vitamin D were obtained to examine the possible development of an innate immune response and possible anti-inflammatory response. Student's t -test, Wilcoxon rank-sum, and Chi-squared with Bonferroni corrections were used to compare groups. Multiple imputations were performed for missing data., Results: Cortisol was higher in babies of both mothers who were vaccinated ( p  = 0.001) and SARS-CoV-2 positive/IgG positive ( p  = 0.009) as compared to the control group suggesting an attempt to maintain homeostasis in these groups. Measurements of ferritin, CRP, and vitamin D did not reach statistical significance. CBC showed no variation, except for the mean platelet volume (MPV), which was elevated in babies whose mothers were vaccinated ( p  = 0.003) and SARS-CoV-2 positive/IgG positive ( p  = 0.007) as compared to the control group., Conclusion: Acute phase reactant elevations were not noted in our neonates. Vitamin D levels were unchanged from homeostatic levels. Cord blood at birth, showed Cortisol and MPV higher in vaccinated and SARS-CoV-2 IgG positive mother/baby dyads as compared to the Control group, indicating that possible anti-inflammatory response was generated. The implication of possible inflammatory events and subsequent cortisol and/or MPV elevation effects upon the fetus after SARS-CoV-2 disease or vaccination is unknown and merits further investigation., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Mendenhall, Hogan, Nudelman, Preston, Weese, Muckleroy, Needens, Addicott, Haas, Roybal, Miller, Cottrell, Massey and Govindaswami.)

Objective: The primary method of drug delivery to treat asthma is through pressurized metered dose inhalers (pMDI). Asthma guidelines recommend that providers prescribe a spacer for all patients using pMDI. The objective of this study was to examine whether microbial contamination of spacer devices is associated with poor asthma outcomes., Methods: This was a cross-sectional, single-center case series of seven pediatric patients with persistent asthma who had previously been prescribed a spacer. Spacers were swabbed with sterile cotton and samples assessed for bacterial/fungal growth. Parents completed a questionnaire including Asthma Control Test (ACT) and asthma control was assessed by an Allergist/Immunologist physician., Results: Two ( n  = 2) children's parent-completed ACT score indicated poorly controlled asthma and three ( n  = 3) patients were noted to be poorly controlled by the physician. All but one caregiver reported cleaning the spacer with most reporting ( n  = 5) that they cleaned their child's spacer monthly and one ( n  = 1) reporting cleaning it every two weeks. One spacer had detected Candida albicans . There was not a statistically significant association between ACT score and microbial growth ( p  > 0.05)., Conclusion: Most spacers in a pediatric sample were not contaminated, despite lack of consistent cleaning, as recommended by spacer manufacturers. Providers and pharmacists should discuss proper cleaning of spacers with caregivers of pediatric patients.

Objectives : Atopic dermatitis, or eczema, is an inflammatory illness that impacts individuals of all ages. The cost of treating AD and the impact on the quality of life have not been well documented in the state of Nevada. This study seeks to fill this gap by identifying factors that impact the cost of AD in the state utilizing clinical and patient demographics. Methods : ANOVA with Bonferroni adjustment was performed using a large hospital utilization database to examine the cost of AD in the state of Nevada across all hospital settings. Results : Several significant factors were associated with the overall cost of AD in Nevada, including hospital setting type (outpatient vs. inpatient), physician type, region, AD diagnosis level, and age (p < 0.05). Stratified analysis was performed by setting type. In the inpatient setting, region, diagnosis level, and records with age listed between 0 and 5 years remained significant (p < 0.05). In the outpatient setting, physician type, region, and African American race remained significant (p < 0.05). Conclusions : Data from this study indicate that the AD cost burden is dependent on both demographic and clinical factors in the state of Nevada. These differences suggest that patients with AD may encounter higher costs depending on age, race, and clinical factors.

Eosinophilic esophagitis (EoE) is a rare, immune-mediated illness. We aimed to examine the comorbidities and sensitization patterns associated with an EoE diagnosis in Nevada. The study goal was two-fold: to determine the most common EoE comorbidities and sequela in the state of Nevada using healthcare utilization records across all settings and to determine the most common food and aeroallergens in histologically positive EoE pediatric patients using clinical sensitization data. Esophageal obstruction/stricture was the most frequently reported diagnosis in adults with EoE (29.5%). Among pediatrics, the highest ranking comorbidities included asthma (13.4%); diseases of the stomach, duodenum, and intestine (7.26%); allergies (7.01%); and gastroesophageal reflux disease (GERD) (3.69%). Additionally, the top sensitizations reported in histologically positive EoE patients were largely pollen related (82.9%). Atopic disease and specifically food allergens are commonly reported as comorbid conditions with EoE in the literature. However, our clinical pediatric data set from this study revealed that aeroallergen sensitizations far exceeded that of food allergens (82.9% aero-positive vs. 17.1% dood positive). The high presence of esophageal stricture/obstruction in adults could be indicative of late diagnosis; in addition, the aeroallergen sensitization in children could suggest different clinical management techniques necessary may be needed for this disease. Education among healthcare providers regarding the presence of aeroallergen sensitization in this population may result in earlier diagnoses and help reduce morbidity and the cost from this disease., (© The Author(s) 2020. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: Eosinophilic esophagitis (EoE) is a rare immune-mediated esophageal disorder that has been documented worldwide. Prior to this study, eosinophilic esophagitis had not been described in the Southwestern state of Nevada. Records containing positive eosinophilic esophagitis diagnosis codes were extracted from a large hospital utilization database and yielded over 2,000 records over 5 years (2013-2017)., Methods: Descriptive statistics were used to identify the overall population demography. Logistic regression was used to determine the factors associated with an eosinophilic esophagitis event in Nevada., Results: Males were 2.93 times more likely (95% CI: 2.53, 3.41; p < 0.001) to have had an eosinophilic esophagitis event when compared to females. Older age was also significant; for each additional year in age the odds of having an eosinophilic esophagitis visit increased by 30% (95% CI: 1.28, 1.31; p < 0.001). Finally, individuals living in the Northern region had 1.95 higher odds of an eosinophilic esophagitis event than their Southern counterparts (OR = 1.95, 95% CI: 1.68, 2.26; p < 0.001)., Conclusions: The climate in Nevada makes this study novel, as the climate is unlike other studies reporting EoE disease prevalence. Previous atopic studies in Nevada report that warmer, drier weather leads to increased atopic illness and perennial pollen, which ultimately may be contributing to the higher than expected number of EoE records identified. Given the well-documented relationship between EoE and atopy, Nevada may be a susceptible region for this condition and an ideal location for future studies.

Objectives: The cost of treating the rare eosinophilic esophagitis (EoE) disease and its impact on patients' quality of life have not been well documented in the literature. This study seeks to fill this gap by comparing the cost of EoE with other well-known inflammatory diseases, including Crohn's disease (CD) and celiac disease (CeD)., Methods: A Mann-Whitney U test and multiple logistic regression were used to examine the cost of EoE in the state of Nevada across all hospital settings and its impact on quality of life compared with CD and CeD., Results: Several factors were associated with the overall cost of EoE in Nevada, including patients' age, sex and region (P < 0.001). EoE was significantly more expensive to treat in the pediatric group ($4001 EoE; $985 CD; $856 CeD), among men ($2532 EoE; $1500 CD; $1724 CeD), among those residing in the southern region of Nevada ($4501 EoE; $2538 CD; $1888 CeD), and among patients seeking medical care from outpatient clinics ($3298 EoE; $741 CD; $1686 CeD) (P < 0.001). Age, sex, region and hospital setting were all associated with having a positive EoE record compared with CeD or CD (P < 0.001)., Conclusions: Data from this study indicate that the EoE burden is significantly higher in cost for certain demographics and regions compared with CD and CeD in the state of Nevada, specifically among pediatric and male patients. These differences suggest that clinicians may encounter similar issues when treating EoE., (© 2020 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.)

Objective: Asthma action plans (AAPs) provide asthma management instructions to families; however, AAPs typically are written at a 7th-9th grade reading level, making them less useful in lower literacy families. There is a need to develop simpler AAP formats and content to optimize their utility across all families, including those who are rural and may be at a risk for literacy concerns. Because using pictures can simplify and enhance health education, our study's aim was to develop a pictorial AAP through a series of focus groups with key stakeholders - youth with asthma, caregivers, and physicians., Methods: Fourteen caregiver/youth dyads and four physicians participated in separate focus groups where their preferences for pictorial AAP structure and content were obtained. Focus groups were audio recorded, transcribed, coded with ATLAS.ti, and analyzed for themes., Results: Youth and their caregivers prefer that the AAPs include simple, cartoon-like pictures customized to the patient. Physicians emphasized AAP's capability to display pictures of controller medication given its importance in preventing asthma exacerbations. A stoplight format, currently used in most written AAPs, received positive reviews. Specific suggestions for pictures showing symptoms, medications, and how to take medication were suggested. Words and short phrases accompanying the pictures were thought to add clarity., Conclusions: Key stakeholders viewed pictorial AAPs as positive and potentially effective alternatives to standard written AAPs. It is expected that low literacy youth and caregivers would more easily understand a pictorial AAP presentation, which should facilitate better medication adherence and asthma outcomes in these children.

Objectives: Children with comorbid asthma and obesity present with more severe and harder-to-control disease than asthmatic children at healthy weight. Weight loss has been shown to improve asthma symptoms, yet physical activity may be difficult due to exercise-induced bronchospasm. Children with asthma have lower exercise rates than non-asthmatics. The objective of this study was to retrospectively evaluate attrition rates and program outcome measures (Body Mass Index [BMI] and maximum oxygen consumption [VO 2 max]) among asthmatic and non-asthmatic participants., Study Design: Clinical data were collected from the Healthy Hearts Program, a 12-week nutrition and activity intervention program for children who are overweight, obese, or at risk for heart disease and other conditions, and used for the study., Methods: Intervention data and demographics were obtained from medical records at the Children's Heart Center Nevada. Descriptive statistics, paired t-tests, Cox regression analysis, and analysis of covariance were conducted., Results: The mean age of this population (N = 232) was 11 years; 54% were male, 64% were Hispanic, and 37% had asthma. Median time in the program was 9 weeks, and 58% of the population completed the program. Unadjusted analyses showed significant BMI decreases in asthmatic (P = 0.002) and non-asthmatic (P = 0.001) participants and increases in cardiorespiratory function for asthmatic males and females (P = 0.003, P = 0.004) and non-asthmatic males and females (P < 0.001 for both). Asthmatic and non-asthmatic children both had improved exercise intensity (P = 0.033, P < 0.001)., Conclusions: This program is both beneficial and practical for obese children with asthma for losing weight and improving cardiorespiratory function., (Copyright © 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Bullous skin lesions are uncommon in children. While it is well known that Mycoplasma infections are associated with papular skin manifestations, bullous skin lesions are not commonly reported. Mycoplasma pneumoniae is a very common bacterial pathogen causing respiratory tract infection in children and adults. We report 2 children with serology-confirmed Mycoplasma infection who were hospitalized for blistering skin lesions. Both of our patients responded well to corticosteroids and one of them required intravenous immunoglobulin. The aim of this case report is to raise awareness that Mycoplasma pneumoniae infection can present with bullous skin lesions, and to briefly review the pathophysiology, diagnosis, and management of the skin manifestation of Mycoplasma infection., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: The majority of pediatric asthma is atopic, but whether pediatric obese asthma is atopic is indeterminate in the literature. In Nevada, children become sensitized to aeroallergens, a risk factor for asthma, at young ages. Additionally, Nevada children have high rates of obesity. Our objective is to determine whether elevated body mass index (BMI) is associated with asthma severity, allergen sensitization, and polysensitization., Methods: Medical records from a pediatric allergy clinic provided BMI percentile, physician-diagnosed asthma severity, skin prick test data, and sociodemographics such as age, race, sex, and insurance status from asthmatic patients. Descriptive statistics and binary and multinomial logistic regression were conducted., Results: In this population (N = 125) aged 1-16, 61% were male, 65% were white, and 74% had private health insurance. Sixty-five percent of children were under/healthy weight and 29% were overweight/obese. Asthma symptoms were moderate in 66% of the population, and severe in 18%. Nearly 85% of this population was atopic, and 82% were polysensitized. Sensitization and polysensitization occurred in all weight categories. Asthma severity and elevated BMI were not associated significantly. Overweight/obese children (≥85 th percentile) had lower odds of allergen sensitization (adjusted odds ratio 0.26, 95% CI = 0.85-0.78, p = 0.016) and polysensitization (adjusted odds ratio 0.30, 95% CI = 0.11-0.85, p = 0.023) than healthy weight children (<85 th percentile)., Conclusion: Although overweight children did show allergen sensitization, those who were overweight had lower odds of allergen sensitization and lower odds of polysensitization, as compared to normal weight asthmatic children. Elevated BMI was not a significant predictor of asthma severity.

Recent studies conducted in the Great Basin Desert region of the United States have shown that skin test reactivity to fungal and dust mite allergens are increased in children with asthma or allergy living in homes with evaporative coolers (EC). The objective of this study was to determine if the increased humidity previously reported in EC homes leads to varying microbial populations compared to homes with air conditioners (AC). Children with physician-diagnosed allergic rhinitis living in EC or AC environments were recruited into the study. Air samples were collected from the child's bedroom for genomic DNA extraction and metagenomic analysis of bacteria and fungi using the Illumina MiSeq sequencing platform. The analysis of bacterial populations revealed no major differences between EC and AC sampling environments. The fungal populations observed in EC homes differed from AC homes. The most prevalent species discovered in AC environments belonged to the genera Cryptococcus (20%) and Aspergillus (20%). In contrast, the most common fungi identified in EC homes belonged to the order Pleosporales and included Alternaria alternata (32%) and Phoma spp. (22%). The variations in fungal populations provide preliminary evidence of the microbial burden children may be exposed to within EC environments in this region.

Background: Clinicians have previously prescribed antihistamines for relief of atopic dermatitis (AD) associated pruritus. The use of antihistamines in AD has recently received less emphasis from newly published practice parameters that currently only recommend short-term, intermittent use of first-generation antihistamines to induce sleep in patients with AD., Objective: Our study aimed to determine parents' perception of the usefulness of antihistamines in reducing their child's itch due to AD., Methods: A 12-question survey was mailed to parents of patients who were attending a pediatric allergy clinic. Patients with physician-diagnosed AD who had a clinic visit in the past 3 years were included. Questions included the following: time since AD diagnosis, itching frequency, impact on sleep, frequency and relief provided from using antihistamines, and comparison of antihistamines to other antipruritus treatments., Results: Sixty-three percent of parents surveyed responded that antihistamines were helpful in the management of their child's AD, and only 5% did not find any itch relief. The majority of the responders were parents of younger patients (ages, 2-10 years) with immunoglobulin E sensitization and AD for more than a year. Eighty-five parents (68.5%) reported no interruption of sleep due to itching, and, among them, an almost equal number were currently solely using either a first- or second-generation antihistamine. The more antihistamines were perceived as relieving itching, the more they were used (ρ = 0.209, p = 0.025) and provided more relief than other products (ρ = -0.336, p < 0.001). When compared, parents ranked antihistamines to be as helpful as topical corticosteroids., Conclusion: Parents of pediatric patients with AD found that antihistamines were an important part of AD management.

Objective: To determine whether a parent-youth teamwork intervention improved medication adherence and related outcomes among youth with asthma., Methods: We used a randomized clinical trial with 48 youth (aged 9-15 years) assigned to 1 of 3 groups: Teamwork Intervention (TI), Asthma Education (AE), or Standard Care (SC). Treatment occurred across 2 months, with a 3-month follow-up assessment. Adherence to inhaled corticosteroids was assessed via the MDILog-II. Parent-adolescent conflict, asthma functional severity, and spirometry assessments were obtained pre-treatment, post-treatment, and on follow-up. Mixed linear model analysis was used to evaluate group and time effects for outcome measures., Results: TI group had significantly higher adherence and lower functional severity scores than AE or SC conditions, and lower parent-reported conflict and a trend for higher spirometry values compared with the SC group., Conclusions: Results suggest support for the efficacy of TI for improving medication adherence as youth acquire more responsibility for their asthma management.

Atopic dermatitis can be due to a variety of causes from nonatopic triggers to food allergy. Control of egress of water and protection from ingress of irritants and allergens are key components of cutaneous barrier function. Current research suggests that a degraded barrier function of the skin allows the immune system inappropriate access to environmental allergens. Epidermal aeroallergen exposure may allow sensitization to allergen possibly initiating the atopic march. Further research into connections between epidermal barrier function and possible allergen sensitization will be important to undertake. Future clinical trials focused on skin barrier protection may be of value as a possible intervention in prevention of the initiation of the atopic march.

Objective: To evaluate the effectiveness of electronic monitoring and feedback to improve adherence in children taking daily asthma controller medications., Method: Five patients with asthma and considered nonadherent participated. Inhalers were electronically monitored with the MDILogII(TM) device, and feedback was given by medical staff. Using a nonconcurrent multiple-baseline design, patients and their parents received bimonthly feedback regarding medication use. Following treatment, feedback was withdrawn and effects of monitoring alone were observed., Results: Three participants showed improvements in adherence following treatment, with more notable increases when baseline adherence was low. Improvements in the inhaler technique occurred for all patients. Some patients demonstrated improvements in lung functioning and functional severity. When feedback was withdrawn, adherence decreased for some participants, but technique improvements maintained., Conclusions: Results support the use of objective monitoring devices for assessing pediatric asthma patients' adherence and indicate that feedback from medical staff may improve and maintain medication adherence for some patients.

Introduction. Aeroallergen sensitization occurs at an earlier age than previously noted. The purpose of this paper was to identify which pollens cause early sensitization in young children presenting with rhinitis symptoms. Methods. This paper was a retrospective analysis of skin test results from 2- to 8-year-old patients presenting with a history consistent with allergic rhinitis. Patients were tested to aeroallergens common to the Great Basin along with a histamine and saline control. Pollen counts were obtained from a Reno, NV-certified counting station. Results. 123 children less than 8 years of age were identified. Over 50% of these children were sensitized to at least one aeroallergen. Chemopodaciae, timothy, alfalfa, black walnut, olive, mountain cedar and willow were predominating sensitizing aeroallergens of the Great Basin Region. Pollen counts were notable for a early spring peak for the tree season, grass season in May and weed season in August. Pollen levels continued to November at low levels. Discussion. Aeroallergens causing early sensitization differed from those which had predominately been reported in other regions of the United States. Pediatric allergists should consider performing a local review of sensitizing aeroallergens in their region to assist with identification and management of allergic rhinitis in their youngest patients. Please make style changes as appropriate.

Phlegmasia cerulea dolens (PCD) is limb-threatening. Traditional treatments are very morbid. We examine the efficacy of percutaneous treatment of PCD. Between May 2005 and September 2008, we treated 21 limbs in 20 patients with lower extremity PCD who were candidates for thrombolysis. Diagnosis was by clinical examination and duplex ultrasound. Catheter access to the deep venous system was obtained through a popliteal vein. Therapy used pulse spray thrombolysis with tissue plasminogen activator (tPA). Infusion catheters and adjunctive percutaneous techniques were used as indicated. Postoperatively, patients were treated with systemic anticoagulation, compression hose, and interval follow-up. Limbs were graded according to the CEAP classification. Twenty patients (13 male) were treated with a mean age of 55.8 years. Nine patients had hypercoagulable states, four May Thurner syndrome, three a history of cancer, one postcolon resection, one acute myocardial infarction, and one postfemoral vein puncture. All patients had resolution of PCD without the need for open surgery. The initial tPA dose was 19.5 mg with pulse spray thrombolysis. Infusion catheters were required in 18 patients and used for 16.1 hours (range, 8 to 36 hours) until complete thrombolysis. Venous angioplasty was necessary in 14 patients with nine of these requiring venous stents. One patient required above-knee amputation despite successful treatment of her PCD. Mean follow-up was 10.7 months (range, 1 to 39 months). All patients demonstrated no or minimal residual thrombus and intact valvular function and a mean clinical CEAP score of 2.4. Percutaneous treatment of PCD produced excellent results with minimal morbidity.

Dust mites and molds are usually not found in arid environments and have a lower prevalence in desert areas. Evaporative (swamp) coolers increase indoor humidity significantly. The purpose of this study is to determine whether evaporative coolers affect the skin test rate to dust mites and molds in patients. Patients with asthma or allergic rhinitis who were undergoing skin testing for molds, indoor allergens, grasses, weeds, and trees were asked about presence of central, window, and evaporative cooler air conditioning in their home. All were tested using the prick technique with controls. One hundred ninety patients between 1 and 42 years (mean, 5.4 years) were evaluated. Fifty-nine (31%) had an evaporative cooler in their home. Twenty-five (42%) of those with evaporative coolers had a positive skin test to at least one mold compared with 26 (19%) without coolers (chi-square, 10.5; p = 0.001). Twenty (34%) of those with evaporative coolers had a positive skin test to dust mites compared with 23 (17.5%) without coolers (chi-square, 6.2; p = 0.013). Children < or = 6 years of age had the greatest skin test prevalence (chi-square, 4.3; p = 0.03). In the desert, children in homes using evaporative coolers are significantly more likely to have positive skin tests to molds or mites. This appears to be because of humidity caused by these devices. Patients with asthma in homes with evaporative coolers should be counseled about the risk for mold and dust-mite allergy. Humidity monitoring, cooler maintenance, and filter changes should be discussed.

Otitis media is one of the most common childhood infections and may result from a variety of underlying problems. Suspicion of immunodeficiency should increase when ear infections are frequent; suppurative; unresponsive to antibiotics; caused by unusual organisms; or seen in the context of other frequent infections, severe eczema, or failure to thrive. Humoral immune deficiencies, particularly with an inability to make antibody to encapsulated organisms, are the immunodeficiencies most likely to cause increased otitis media. Immune system evaluation should concentrate on humoral immunodeficiency disorders, but the presenting history and physical findings also should be considered when designing the work-up. Treating the underlying immune deficiency is usually necessary to adequately control the ear infections.

Exposure to indoor fungi is of growing concern in residential and occupational environments in the United States. The purpose of this study was to determine the prevalence of sensitization to common indoor fungal species in an atopic population. We evaluated 102 patients (73 female and 29 male patients) for immunoglobulin E (IgE) reactivity to a panel of skin-prick test (SPT) reagents used for routine allergy testing. Patients also were tested for six additional fungi that are common indoor contaminants. All patients had symptoms consistent with allergic rhinitis or asthma. The presence of specific IgE against the fungal species was determined using immunoblotting. Of the 102 eligible patients, 68% had at least one positive skin test. The most prevalent positive SPTs were to dust mites, cats, vernal grass, and short ragweed. Overall, 21/102 (21%) patients with asthma or allergic rhinitis were skin test positive to at least one fungal extract. Of the patients with a positive SPT to fungi, 12/21 (58%) showed sensitivity to one or more of the newly tested species; most notably Trichoderma viride (8%), Chaetomium globosum (7%), Paecilomyces variotii (7%), and Acremonium strictum (6%). Immunoblotting revealed specific IgE against a number of protein bands belonging to these fungal species. The prevalence of fungal sensitization was common, particularly for indoor fungal contaminants that are not routinely included in SPT panels. Cross-reactivity with other fungi may partially explain our results; however, skin testing for these indoor fungi may provide useful diagnostic information.

It is commonly believed that young children are incapable of pollen sensitization; therefore, skin testing usually is not performed to these allergens. The purpose of this study was to identify the frequency of positive skin tests to outdoor allergens among younger children who have asthma. Patients who have asthma, aged 6 months to 10 years, were evaluated for pollen sensitization over a 10-year period. Skin-prick testing was performed to relevant individual aeroallergens including trees, grasses, and weeds. Testing for perennial indoor allergens such as dust mites, cats, dogs, cockroaches, and molds was performed also. A total of 687 children with asthma were evaluated. No child <12 months old was sensitized to pollens. Children between 12 and 24 months of age had a 29% incidence of pollen sensitization. Three-year-old children were as likely to be skin test positive to pollen as an indoor allergen. Notably, 49% of 3- and 4-year olds were sensitized to outdoor allergens. Primary sensitizing pollens in this age group were short ragweed, box elder, and June grass. In this population, pollen sensitization was not related to tobacco or wood smoke exposure. Although it is widely believed that young children with asthma are most commonly allergic to indoor allergens, almost 40% of our 1- to 3-year old children with asthma showed IgE-mediated sensitivity to outdoor allergens. Pediatric allergists should consider performing skin-prick testing to their local common aeroallergens in young children with asthma and seasonal symptoms.

Background: Common variable immunodeficiency (CVID) may present at any age but usually presents during adulthood., Objective: To study the presentation and associated medical conditions found in pediatric patients with CVID., Methods: A medical record review of patients diagnosed as having CVID before the age of 18 years was performed at a tertiary care immunology clinic from 1992 to 2005. Inclusion criteria consisted of presentation with recurrent infections and decrease in 2 of 3 immunoglobulin isotypes (IgG, IgA, IgM) 2 SDs below the age-specific range, with a poor or absent response to immunization. There had to be no other identifiable predisposing cause of the immunodeficiency., Results: A total of 12 patients were identified. The mean age at presentation was 8 years. All patients had low IgG levels with poor functional antibody responses. The most common presenting infections were sinusitis (75%), otitis media (67%), and pneumonia (58%). Bronchiectasis was seen in 3 children. One patient presented with chronic diarrhea due to Giardia. Two patients presented with failure to thrive. Asthma was seen in 10 patients (83%) but was usually diagnosed after the initial presentation. Autoimmune disorders were seen, including 1 patient with idiopathic thrombocytopenia and 2 with neutropenia. Other disorders encountered were growth hormone deficiency, hypothyroidism, end-stage renal disease, and sarcoma., Conclusions: CVID is a difficult diagnosis in the pediatric population because of an unpredictable presentation. Autoimmune disease, growth hormone deficiency, renal disease, and cancer were noted in our population. A high incidence of asthma also may be associated with pediatric CVID.

Background: Children with chronic illness have been found to be at an increased risk of behavioral and emotional difficulties. To date, children with pediatric immunodeficiency disorders (PIDDs) and their families have not been the focus of extensive published psychosocial research., Objective: To determine if children with PIDDs and their caregivers have altered psychosocial function and whether the severity of the PIDD was associated with such difficulties., Methods: Twenty children with PIDDs and 20 children with asthma were recruited for this study. Children and their caregivers completed various psychosocial questionnaire forms. Responses were compared with normative data for the appropriate measure and with other variables., Results: Higher frequencies of children with PIDDs were found to have a number of elevated psychosocial concerns when contrasted with normative data, particularly from parent report. These concerns included depression, anxiety, somatization, social withdrawal, and social skills. The severity of the PIDDs was significantly associated with a number of behavioral adjustment issues, including receiving psychiatric diagnoses and special education services. Although children with PIDDs had significantly more psychiatric diagnoses than did asthmatic children, these groups did not differ significantly on questionnaire scores regarding child or caregiver psychosocial adjustment., Conclusions: Children with PIDDs have significant behavioral problems. Children receiving intravenous immunoglobulin or immunomodulatory treatments were reported to have more problems than children not receiving them. This study highlights the need for further research in psychosocial functioning of children with PIDDs in an effort to develop interventions to promote their overall adjustment.

Inhalant allergy to insects other than cockroaches and dust mites was described in the 1950s, but little attention has been paid to these findings. Sensitization rates for many allergens have increased since then. In this rural population, we describe the current prevalence of sensitization to commonly found insects. We evaluated 200 patients (38 adults and 162 children), for immunoglobulin E (IgE)-mediated sensitization to the caddis fly, mayfly, moth, carpenter ant, and housefly using the prick technique and commercially available whole-body extracts. All had symptoms consistent with asthma and/or allergic rhinitis. They also were tested to indoor and outdoor aeroantigens. Of the 200 patients, 60 patients (30%) tested positive to at least one of the five insects. The most prevalent positive skin test was to the mayfly (37/60), followed by the housefly (36/60), caddis fly (27/60), moth (14/60), and ant (10/60). Of the 60 patients positive for insects, 35 patients (58%) also tested positive to at least one species of mite, 36 patients (60%) tested positive to the cockroach. Twelve of the 60 patients (20%) with positive insect testing did not react to either cockroaches or mites. In our patients, the immunoglobulin E-mediated sensitization rate to insects excluding cockroaches is 30%. Many patients also were sensitized to mites and/or cockroaches. These insects are all present in the indoor/outdoor environment of this rural population. Cross-reactivity with mites and cockroaches (insect panallergy) may partially explain our results. The presence of skin test sensitivity in the absence of cockroach or mite allergy suggests possible true insect sensitization.

Background: Primary ciliary dyskinesia (PCD) results in impaired mucociliary clearance. Patients with this disorder develop chronic sinopulmonary disease with recurrent sinusitis, otitis media, nasal polyposis, pneumonia, and, ultimately, bronchiectasis. Other associated findings of dysfunctional ciliary activity include situs inversus, dextrocardia, and infertility., Objective: To describe our 10-year experience using a small, plastic, disposable curette to perform a screening procedure for cilia function and to collect samples for electron microscopy., Methods: In the past 10 years, we screened infants and children with severe chronic sinusitis and other chronic recurrent upper respiratory tract problems for PCD by using a plastic, disposable curette to collect tissue samples from the nasal mucosa. Samples were placed in sterile saline and examined under light microscopy for the presence of cilia. Failure to note ciliary movement prompted another examination 1 month later. If no functional cilia were noted at the follow-up examination, a specimen was obtained and sent for electron microscopy., Results: We identified 7 patients with PCD; 2 had situs inversus totalis. Average age at diagnosis was 3 years. The most common symptom at presentation was frequent upper respiratory tract infections with severe otitis media (7 patients) and sinusitis (5 patients). Recurrent pneumonia was present in 6 patients. Dynein arm deficiency was the most common electron microscopic diagnosis., Conclusions: Evaluating children for PCD by using a plastic, disposable curette is a relatively simple procedure that could be used by allergists in practice. Primary ciliary dyskinesia occurs frequently enough that physicians should consider it as part of the differential diagnosis in evaluating children with recurrent, severe sinopulmonary infections.

This study evaluated the effect of fenoldopam, a selective dopamine (DA1) agonist, on renal blood flow and renal tubular function following renal ischemia induced by suprarenal aortic cross-clamping. Twenty anesthetized research pigs received either fenoldopam (10 micro g/kg/min; n = 10) or saline ( n = 10) beginning 20 min before suprarenal aortic cross-clamping and continuing for 20 min after clamp release, for a total infusion time of 160 min (120-min cross-clamp). Recordings of renal blood flow, mean arterial pressure, and heart rate were taken at baseline, during cross-clamping, and immediately postclamp. Ischemic renal injury was evaluated by serum creatinine and by histologic grading of acute tubular necrosis. Treatment with fenoldopam increased renal blood flow in comparison to that in the control group ( p = 0.03). The mean creatinine increase from baseline at 6 hr and 18 hr after cross-clamp removal for the fenoldopam-treated group was significantly less than that in the control group ( p < 0.001). On histologic evaluation, the mean score for the degree of tubular necrosis was significantly higher in the control group ( p = 0.02), indicating less derangement of tubular morphology in the fenoldopam group. This study demonstrated that the intraoperative use of a continuous infusion of fenoldopam during suprarenal aortic cross-clamping results in increased renal blood flow, less postoperative rise in creatinine, and better preservation of tubular histology in the pig model.

Eosinophilic inflammation plays a key role in tissue damage that characterizes asthma. Eosinophils are produced in bone marrow and recent observations in both mice and humans suggest that allergen exposure results in increased output of eosinophils from hemopoietic tissue in individuals with asthma. However, specific mechanisms that alter eosinophilopoiesis in this disease are poorly understood. The current study used a well-characterized murine animal model of asthma to evaluate alterations of eosinophil and eosinophil progenitor cells (CFU-eo) in mice during initial sensitization to allergen and to determine whether observed changes in either cell population were regulated by T lymphocytes. Following the first intranasal installation of OVA, we observed sequential temporal elevation of eosinophils in bone marrow, blood, and lung. In immunocompetent BALB/c mice, elevation of bone marrow eosinophils was accompanied by transient depletion of CFU-eo in that tissue. CFU-eo rebounded to elevated numbers before returning to normal baseline values following intranasal OVA exposure. In T cell-deficient BALB/c nude (BALB/c(nu/nu)) mice, CFU-eo were markedly elevated following allergen sensitization, in the absence of bone marrow or peripheral blood eosinophilia. These data suggest that eosinophilia of asthma results from alterations in two distinct hemopoietic regulatory mechanisms. Elevation of eosinophil progenitor cells in the bone marrow is T cell independent and likely results from altered bone marrow stromal cell function. Differentiation of eosinophil progenitor cells and phenotypic eosinophilia is T cell dependent and does not occur in athymic nude mice exposed to intranasal allergen.

Introduction: The most critical dust mite avoidance technique for asthmatic children with mite allergy is the use of dust mite-proof bedding covers. Adherence to allergen control measures is poor due to cost. The purpose of this study was to determine whether giving families mite-proof bedding encasings at the time of the diagnosis with mite allergy would improve adherence at a home visit 2 months later., Methods: Parents of children (mean age 7.7 years) with asthma and positive skin tests for dust mite were assigned either to an intervention group, which received dust mite covers upon enrollment or a comparison group, which did not. Both groups were instructed in dust mite control measures by a medical provider and told to invest in the covers as part of standard care. Two months after enrollment, parent report and observational measures from each family were obtained during a home visit., Results: The group provided allergen encasings was found to be significantly more likely to have used the casings at the home visit, t(22) = 2.77, P < 0.05. There were no differences between groups in adherence to other mite control strategies. Parenting stress was significantly related to poorer mite control compliance. The most common reason reported for nonadherence to control measures was cost., Conclusions: Providing mite bedding encasings at the time of diagnosis significantly increases compliance at a 2-month home visit. Medicaid and insurance companies should be encouraged to pay for casings as a cost effective measure to improve asthma care in children with mite allergy.

Background: Mice are a common finding in the indoor environment of many homes. In a recent study, 18% of children with asthma from an inner-city environment were reported to be allergic to mouse allergen., Objective: To determine the frequency of skin test reactivity among asthmatic children in a rural environment., Methods: We consecutively evaluated 209 (82 female, 127 male) children between the ages of 5 months and 19 years with asthma for mouse allergy. A careful environmental history was obtained on all children. Children older than 3 years of age were skin tested to mouse allergen and other indoor/outdoor inhalant allergens. Children younger than 3 years were skin tested to mouse and indoor allergens., Results: Thirty-three percent of parents reported seeing mice in their homes. Overall, 25 of 209 (12%) children with asthma were skin test-positive for mouse. For children 3 years or younger, 6 of 52 were skin test-positive for mouse (12%). There was no correlation among socioeconomic status, skin test reactivity, and the presence of mice in the home. Children with multiple skin test reactions were more likely to be reactive to mouse (P < 0.01). Mice seen in the home did not correlate with positive mouse skin tests., Conclusions: The frequency of skin test reactivity to mouse allergen in asthmatic children from rural areas appears slightly less than that in children from inner-city environments. However, a frequency of 12% suggests that skin testing for this allergen provides useful information for environmental control measures in the home.