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Telemedicine adoption has rapidly accelerated since the onset of the COVID-19 pandemic.1 Telemedicine provides increased access to medical care and helps to mitigate risk by conserving personal protective equipment and providing for social/physical distancing in order to continue to treat patients with a variety of allergic and immunologic conditions. During this time, many allergy and immunology clinicians have needed to adopt telemedicine expeditiously in their practices while studying the complex and variable issues surrounding its regulation and reimbursement. Some concerns have been temporarily alleviated since March 2020 to aid with patient care in the setting of COVID-19. Other changes are ongoing at the time of this publication. Members of the Telemedicine Work Group in the American Academy of Allergy, Asthma & Immunology (AAAAI) completed a telemedicine literature review of online and Pub Med resources through May 9, 2020 to detail Pre-COVID-19 telemedicine knowledge and outline up to date telemedicine material. This work group report was developed to provide guidance to allergy/immunology clinicians as they navigate the swiftly evolving telemedicine landscape.

The implementation of policies to reduce environmental allergic triggers can be an important adjunct to optimal patient care for allergic rhinitis and allergic asthma. Policies at the local level in schools and other public as well as private buildings can make an impact on disease morbidity. Occupational exposures for allergens have not yet been met with the same rigorous policy standards applied for exposures to toxicants by Occupational Safety and Health Administration. Further benefit may be obtained through policies by local, county, state, and national governments, and possibly through international cooperative agreements. The reduction of allergenic exposures can and should be affected by policies with strong scientific, evidence-based derivation. However, a judicious application of the precautionary principle may be needed in circumstances where the health effect of inaction could lead to more serious threats to vulnerable populations with allergic disease. This commentary covers the scientific basis, current implementation, knowledge gaps, and pro/con views on policy issues in reducing environmental allergic triggers.

I Paciencia, J Cavaleiro Rufo, D Silva. Allergy . 2019;74(7):1277–1291 The goal of this study was to examine the role of specific indoor air contaminants identified as endocrine-disrupting chemicals (EDCs) in the prevalence of asthma and other respiratory symptoms and obesity. A cross-sectional analysis was used with 815 participants from 20 schools in Porto, Portugal, corresponding to a total of 71 classroom assessments. Respiratory symptoms were assessed, lung function and airway reversibility …

M Fazlollahi, Y Chun, A Grishin. Allergy. 2018;73(7):1515–1524 To examine the association between early-life gut microbiota and the development of egg allergy. Data from 141 children, 66 with egg allergy and 75 controls, from the multicenter Consortium of Food Allergy Research study from 5 centers were analyzed. Subjects were enrolled from age 3 to 16 months. Baseline characteristics were as follows: 73% white, 67% boys, 39% breastfeeding, and 90% …

M Greenhawt, DM Fleischer, ES Chan. Allergy. 2017;72(8):1254–1260 To evaluate data from the Learning Early About Peanut Allergy (LEAP) study to determine the risk factors that most influence peanut tolerance. In the analysis, 640 individuals from the LEAP study (ages 4–11 months with a high risk for allergy) who were included in the data set with complete data, including outcomes of a 60-month oral food challenge, were used. In a secondary analysis, the relationships …

B Sousa-Pinto, L Araujo, A Freitas, L Delgado. Int Arch Allergy Immunol. 2018;176(3–4):234–238 To compare patient characteristics and use of hospital resources in hospitalized children with or without a record of penicillin allergy. The study included all hospitalized children from a database of Portuguese public hospitals from 2000 to 2014. Children labeled as having allergy to penicillin were compared with a similar number of age-, …

Indoor environmental exposures, particularly allergens and pollutants, are major contributors to asthma morbidity in children; environmental control practices aimed at reducing these exposures are an integral component of asthma management. Some individually tailored environmental control practices that have been shown to reduce asthma symptoms and exacerbations are similar in efficacy and cost to controller medications. As a part of developing tailored strategies regarding environmental control measures, an environmental history can be obtained to evaluate the key indoor environmental exposures that are known to trigger asthma symptoms and exacerbations, including both indoor pollutants and allergens. An environmental history includes questions regarding the presence of pets or pests or evidence of pests in the home, as well as knowledge regarding whether the climatic characteristics in the community favor dust mites. In addition, the history focuses on sources of indoor air pollution, including the presence of smokers who live in the home or care for children and the use of gas stoves and appliances in the home. Serum allergen-specific immunoglobulin E antibody tests can be performed or the patient can be referred for allergy skin testing to identify indoor allergens that are most likely to be clinically relevant. Environmental control strategies are tailored to each potentially relevant indoor exposure and are based on knowledge of the sources and underlying characteristics of the exposure. Strategies include source removal, source control, and mitigation strategies, such as high-efficiency particulate air purifiers and allergen-proof mattress and pillow encasements, as well as education, which can be delivered by primary care pediatricians, allergists, pediatric pulmonologists, other health care workers, or community health workers trained in asthma environmental control and asthma education.

Introduction: The Centers for Disease Control and Prevention report that the number of individuals with asthma in the United States has increased by 4.3 million, or 12.3%, between 2001 and 2009, creating an increasing burden on our health care system. Effective patient education is a key component of asthma management. The National Asthma Educator Certification Board (NAECB) promotes “optimal asthma management and quality of life by advancing excellence in asthma education through the Certified Asthma Educator process.” Methods: Following completion of the asthma educator certification examination, applicants were invited to participate in a voluntary, anonymous Web-based survey. The survey was developed and approved by the Executive and Research Committees of the NAECB, with the objective of reviewing the experience of applicants seeking initial certification and of those seeking recertification. Results: Completed surveys were obtained from 988 applicants. Seventy-six percent of respondents were first-time test takers; the remaining respondents were repeat test takers. Eighty percent reported having passed the examination. Approximately 85% felt that the time allotted for the examination was “just right”; the level of difficulty was “ just right” for 65% of the respondents, and the clarity of the examination questions was rated as “good” or “excellent” by 72% of the respondents. Seventy-two percent responded that the examination reflected the role of the asthma educator and 88.1% would recommend the examination to others interested in asthma education. Open-ended responses highlighted benefits and barriers. Discussion: The asthma educator certification examination is reflective of the professional responsibilities of the asthma educator. Benefits and barriers are discussed in the context of published literature.

HM Wolsk, BL Chawes, NV Folsgaard. Allergy. 2016;71(6);820–828 To determine whether having siblings affects the airway immune response in healthy neonates, a characteristic that could be attributed to an underlying immune modulatory pathway. Five hundred seventy-one 1-month-old, asymptomatic neonates from the Copenhagen Prospective Studies on Asthma in Childhood 2010 (COPSAC2010) birth cohort were studied. Unstimulated airway mucosal lining fluid was sampled via the nose at 1 month …

Asthma and related respiratory tract allergic diseases are among the most common chronic diseases of adults and children. Despite their importance, disease course cannot be predicted and treatment remains non-specific and potentially hazardous, with no means for cure. Improved clinical management of asthma will require an improved understanding of the fundamental factors that initiate allergic inflammation, especially T helper type 2 (T(H)2) cell induction.In this review, we explore the Proteinase Hypothesis of allergic airway disease, considering specifically how organismal proteinases contribute to the expression of allergic disease and potentially important proteinase signaling pathways.Proteinases from diverse sources (bacteria, fungi, plants) may cause occupational asthma by acting as immune adjuvant factors that specifically elicit T(H)2 cell-dependent allergic inflammation. However, more conventional allergic airway diseases (asthma, allergic sinusitis) are more likely to arise from contained fungal or viral infections of the airway in which proteinases are produced and serve as major virulence factors. Proteinases may elicit allergic disease by disrupting numerous cellular proteins, potentially including Toll like receptor (TLR) 4, but critical proteinase-activated signaling pathways remain largely unknown.Clarification of how proteinases cause allergic disease, specifically confirming an infectious basis for airway proteinase exposure, will likely radically advance how asthma and related respiratory tract disorders are diagnosed and treated. This article is part of a Special Issue entitled Biochemistry of Asthma.

Allergic asthma is an obstructive lung disease linked to environmental exposures that elicit allergic airway inflammation and characteristic antigen-specific immunoglobulin reactions termed atopy. Analyses of asthma pathogenesis using experimental models have shown that T helper cells, especially T helper type 2 (Th2) cells and Th2 cytokines such as interleukin 4 (IL-4) and IL-13, are critical mediators of airway obstruction following allergen challenge, but the environmental initiators of lung Th2 responses are less defined. Our studies demonstrate that fungal-derived proteinases that are commonly found in home environments are requisite immune adjuvants capable of eliciting robust Th2 responses and allergic lung disease in mice. We have further shown that common household fungi readily infect the mouse respiratory tract and induce both asthma-like disease and atopy to otherwise innocuous bystander antigens through the secretion of proteinases. These findings support the possibility that asthma and atopy represent a reaction to respiratory tract fungal infection, suggesting novel means for diagnosis and therapy of diverse allergic disorders.

KB Fieten, JEE Totte, E Levin. Int Arch Allergy Immunol. 2018;175(1–2):77–84 To determine whether particular microbial species in the gut are associated with food allergy. Pediatric patients with atopic dermatitis (AD), with or without food allergy and partaking in a Western diet, were included in a cross-sectional observational pilot study. A total of 82 children with AD with a median age of 2.5 years, 20 of whom were diagnosed …

Live pentavalent human-bovine reassortant rotavirus vaccine is recommended in the United States for routine immunization of infants. We describe three infants, two with failure to thrive, who had dehydration and diarrhea within 1 month after their first or second rotavirus immunization and subsequently received a diagnosis of severe combined immunodeficiency. Rotavirus was detected, by means of reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay, in stool specimens obtained from all three infants, and gene-sequence analysis revealed the presence of vaccine rotavirus. These infections raise concerns regarding the safety of rotavirus vaccine in severely immunocompromised patients.

Active fungal proteinases are powerful allergens that induce experimental allergic lung disease strongly resembling atopic asthma, but the precise relationship between proteinases and asthma remains unknown. Here, we analyzed dust collected from the homes of asthmatic children for the presence and sources of active proteinases to further explore the relationship between active proteinases, atopy, and asthma. Active proteinases were present in all houses and many were derived from fungi, especially Aspergillus niger. Proteinase-active dust extracts were alone insufficient to initiate asthma-like disease in mice, but conidia of A. niger readily established a contained airway mucosal infection, allergic lung disease, and atopy to an innocuous bystander antigen. Proteinase produced by A. niger enhanced fungal clearance from lung and was required for robust allergic disease. Interleukin 13 (IL-13) and IL-5 were required for optimal clearance of lung fungal infection and eosinophils showed potent anti-fungal activity in vitro. Thus, asthma and atopy may both represent a protective response against contained airway infection due to ubiquitous proteinase-producing fungi.

X-linked lymphoproliferative disease (XLP) is a primary immunodeficiency affecting approximately 1 to 3 per million live male births. Patients are generally healthy until facing a viral infection such as Epstein-Barr Virus and then may develop fulminant infectious mononucleosis and die. XLP patients are also at increased risk of hemophagocytic lymphohistiocytosis (HLH), which may be triggered by assorted viruses. Here we report a novel case of HLH in a patient with XLP. Significant to his presentation is a paradoxical increase in natural killer (NK) cell activity. We hypothesize that this indicates that Parvovirus B19 activates NK cells via a signaling lymphocytic activation molecule-associated protein (SAP)-independent mechanism. Our case demonstrates an important etiology to consider in the differential diagnosis of XLP patients with nonfocal findings and febrile illnesses.

Background Between 1981 and 1995, 20 children with severe combined immunodeficiency (SCID; median age at transplant, 6.5 [range, 0.5-145] mo, 12 with serious infection) were treated with haploidentical T cell–depleted (anti-CD6 antibody) bone marrow (median number of 5.7 [0.8-18.8] × 10 8 nucleated cells/kg) from mismatched related donors (MMRDs), and 5 children with SCID (median age at transplant, 1.8 [0.5-5.0] mo, 1 with serious infection) were given unmanipulated bone marrow from matched related donors (MRDs). No conditioning or graft-versus-host disease (GvHD) prophylaxis was used. Objective To assess the outcomes of patients with SCID who received bone marrow from MMRDs or MRDs. Methods We reviewed the medical records of these 25 consecutive patients with SCID (4 with Omenn syndrome). Results Of the 20 patients who received bone marrow from MMRDs, 12 engrafted, 10 survived at a median age of 15.2 [10.0-19.1] years, 4 had chronic GvHD (lung, intestine, skin), 5 required intravenous immunoglobulin, and 8 attended school or college. Two of 5 patients who died had chronic GvHD, and 2 developed lymphoproliferative disease. Of the 5 patients who received bone marrow from MRDs, 5 engrafted, 5 survived at a median age of 23.3 [18.5-26] years, 1 had chronic GvHD (lung, skin), 2 required intravenous immunoglobulin, and 4 attended school or college. Conclusions Treatment of critically ill patients with SCID with anti-CD6 antibody T cell–depleted MMRD marrow resulted in an overall 50% long-term survival of patients (83% survival of those engrafted). The principal barriers to long-term survival were delay in diagnosis, life-threatening infection, failure to engraft, and chronic GvHD. Educational goals were achieved in most of the survivors.

In the United States, the prevalence of asthma is greater in urban African American children than their white counterparts, but data for Hispanic children are not consistent. Prevalence of asthma in “Hispanic ” children may be dependent on one or more factors such as of socioeconomic status, geographic location, and country of origin. We screened a predominately African American and Mexican American population of poor children in a large city for self-reported symptoms that might suggest asthma and then asked their parents about both symptoms and diagnosis of asthma. A video-guided yes/no questionnaire was administered in the fall of 1997 to 21,852 children in grades 1–4 (ages 6–10) in 60 schools; a questionnaire was then sent to the parents of the 10,454 children who reported at least one asthma symptom. Asthma had already been diagnosed in 8.16%. However, 51% of the children whose parents reported daytime wheezing (10.46%) had not received a diagnosis of asthma. Percentages of wheeze ranged from 5% of A...

Clinical guidelines can assist in the management of asthma. Decision support systems (DSSs) can enhance adherence to clinical guidelines but tend not to provide clinicians with cues for behavioral change strategies to promote patient self-management. The Stop Asthma Clinical System (SACS) is a DSS designed for this purpose. To assess feasibility, seven clinicians used SACS to guide well visits with 26 predominantly persistent pediatric asthma patients. Data were collected via survey and in-depth semi-structured interviews. SACS improved assessment of asthma severity and control, classification of and intervention in medicine and environmental trigger management problems, and development of an action plan (all p< 0.05). Clinician-patient communication was enhanced. The primary challenge was that SACS increased clinic visit time. SACS can enhance clinician behavior to improve patient asthma self-management, but more studies are indicated to mitigate temporal constraints and evaluate impact on clinician and patient communication and behavior as well as clinical outcomes.

Environmental allergens are major triggers for pediatric asthma. While children’s greatest exposure to indoor allergens is in the home, other public places where children spend a large amount of time, such as school and day care centers, may also be sources of significant allergen encounters. The purpose of this article is to describe schoolroom allergen levels from 3 different geographic sites obtained from dust samples collected in the, fall and in spring. Environmental dust samples were collected from elementary schools in Birmingham (AL), Detroit (MI), and Houston (TX), from 4 room locations, including the cafeteria, library, upper grades, and lower grades. Samples were assayed for dust mite (Dermatophagoides pteronyssinus and Dermatophagoides farinae), cat (Felis domesticus), and cockroach (Blatella germanica 2) allergen levels. Allergen levels varied by geographic location and type of schoolroom. Schoolroom settings differed by the type of flooring (hard and carpet), room characteristics and use (food service, library shelves with books, and general classroom with multiple types of materials [individual desks and different types of furniture]), and the average age of the schoolroom dwellers (younger vs older children). Dust mite, cat, and cockroach allergens were present in all schoolrooms and all sites at varying levels by season and by type of room. Schools may be important sources of direct allergen exposure and reservoirs that could potentially contribute to allergic sensitization and, disease exacerbation in. children. Further studies are needed to carefully examine the environmental allergen load in schools and its effect on children.

A 5-week-old female infant with vertical HIV-1 exposure, progressive cough, and failure to thrive was given a diagnosis of bilateral diffuse nodular lung lesions. The child was without fever, leukocytosis, anemia, peripheral adenopathy, or hepatosplenomegaly, and the results of repeated blood tests for HIV-1 DNA were negative. A needle biopsy of the lungs revealed granulomatous inflammation and giant cells, with fungal organisms suggestive of Aspergillus species. A nitroblue tetrazolium dye test performed on the patient's blood specimen demonstrated absence of dye reduction, suggesting a diagnosis of chronic granulomatous disease. Further analysis revealed that the child had a deficiency of the p47(phox) component of the nicotinamide adenine dinucleotide phosphate oxidase system. Thus this child with vertical HIV-1 exposure and diffuse pulmonary nodules actually had an autosomal recessive form of chronic granulomatous disease. This case study clearly demonstrates that children with suspected HIV-1 infection might also need evaluation for primary immunodeficiency and that the clinical immunology laboratory is a powerful adjunct in coming to a correct diagnosis.

H Tachimoto, H Mezawa, T Segawa, N Akiyama, H Ida, M Urashima. Allergy. 2016;71(7):1001–1009 To assess whether low-dose, short-term vitamin D supplementation in addition to standard treatment improved control of childhood asthma. Eighty-nine Japanese schoolchildren ages 6–15 years who had a diagnosis of asthma based on GINA criteria and spirometry were randomly assigned to receive vitamin D ( n = 54) or a placebo ( n = 35). Ninety-four percent of subjects were using either an inhaled corticosteroid or a leukotriene …

MI Muniz-Junqueira, SM Barbosa-Marques, LF Junqueira Jr. Allergy. 2013;68(7):911–920 The goal of this study was to determine if morphologic changes in blood eosinophils can be used for early identification of the severity of an acute asthma exacerbation in children. Children were selected sequentially in an emergency care unit or asthma outpatient clinic. They comprised a group of 15 healthy children (5 girls and 10 boys; ages 4–14 years) without asthma or a personal of familial history of allergy, a group of 15 asthmatic children with variable disease severity (3 girls and 12 boys; ages 2–12 years) seen at a symptom-free …

There is concern regarding the underdiagnosis and undertreatment of asthma in children. This pilot study was designed to determine the specificity, sensitivity, and feasibility of using a two-part (child + parent questionnaire) case finding tool (Video-guided Asthma Screening for Children-School Age, VASC-SA) to identify elementary school children with asthma. The child checklist includes two practice items and nine items asking about asthma symptoms and diagnosis. The items are visually cued using a 10-min videotape using split-screen vignettes, one corresponding to a no response (most children do not...) and one to a yes response (some children...). Three case definition algorithms were examined (all included inhaled medication, or current diagnosis, or wheeze with 0, 1, or 2 other symptoms). The VASC-SA was administered to English-speaking children in grades 1-4 from one school. All parents were sent a written asthma questionnaire. Positive screens were compared with diagnosis obtained from physician r...

Objective: To evaluate Watch, Discover, Think and Act (WDTA), a theory-based application of CD-ROM educational technology for pediatric asthma self-management education. Design: A prospective pretest posttest randomized intervention trial was used to assess the motivational appeal of the computer-assisted instructional program and evaluate the impact of the program in eliciting change in knowledge, self-efficacy, and attributions of children with asthma. Subjects were recruited from large urban asthma clinics, community clinics, and schools. Seventy-six children 9 to 13 years old were recruited for the evaluation. Results: Repeated-measures analysis of covariance showed that knowledge scores increased significantly for both groups, but no between-group differences were found ( P = 0.55); children using the program scored significantly higher ( P < 0.01) on questions about steps of self-regulation, prevention strategies, and treatment strategies. These children also demonstrated greater selfefficacy ( P < 0.05) and more efficacy building attribution classification of asthma self-management behaviors ( P < 0.05) than those children who did not use the program. Conclusion: The WDTA is an intrinsically motivating educational program that has the ability to effect determinants of asthma self-management behavior in 9- to 13-year-old children with asthma. This, coupled with its reported effectiveness in enhancing patient outcomes in clinical settings, indicates that this program has application in pediatric asthma education.

To determine the efficacy of high doses of intravenous gammaglobulin (IVIG) for the treatment of severe, steroid-dependent asthma in patients between 6 and 68 years of age, a randomized, double-blind, placebo-controlled multicenter clinical trial was conducted in private and university hospitals in the United States. Patients were randomized to one of three treatment arms: 2 g IVIG/kg/month (16 patients); 1 g IVIG/kg/month (9 patients); or 2 g iv albumin (placebo)/kg/month (15 patients). The treatment consisted of seven monthly infusions followed by a posttreatment observation period. The primary outcome measurement was mean daily prednisone-equivalent dose requirements, determined during the observation month preceding initiation of treatment and compared to the month preceding the seventh infusion. Secondary clinical endpoints measured were pulmonary function, frequency of emergency room visits or hospitalizations, and number of days absent from school or work. When adjusted for body weight, the mean dose requirements fell by 33, 39, and 33% in the placebo, IVIG (1 g/kg), and IVIG (2 g/kg) treatment arms, respectively. The differences between therapies were not statistically different (P = 0.9728). The mean percentage-of-predicted FEV1 fell in all three treatment groups during the treatment period but there was no significant difference between treatment groups (P = 0.8291). There was also no significant difference in the percentage of subjects requiring emergency room visits or hospitalizations or missing days of work/school, among the three treatment groups. The trial was terminated prematurely after interim analysis determined the adverse experience rate was different between the three groups. Three patients, all randomized to the 2-g/kg IVIG dose group, were hospitalized with symptoms consistent with aseptic meningitis. In summary, in this randomized, double-blind, placebo-controlled multicenter study, high doses of IVIG did not demonstrate a clinically or statistically significant advantage over placebo (albumin) infusions for the treatment of corticosteroid-dependent asthma. Subgroup analysis failed to identify markers predicting responsiveness. High-dose IVIG can also be associated with a significant incidence of serious adverse events.

Nineteen children with human immunodeficiency virus (HIV) infection were treated with recombinant human gamma interferon (rIFN-γ) (50 μg/m 2 subcutaneously three times each week during weeks 1 through 12 and 100 μg/m 2 subcutaneously three times each week during weeks 13 through 24) in a phase I/II clinical trial. All children continued to receive previously prescribed therapy with oral zidovudine or didanosine. Children were assessed clinically and with laboratory studies during 24 weeks of study treatment and for 12 weeks after completion of rIFN-γ therapy. In general, rIFN-γ therapy was well tolerated. There were two clinical or laboratory adverse events thought to be possibly or probably study drug associated. One child developed acute pancreatitis; another child developed granulocytopenia. Median CD4 + -lymphocyte counts and plasma HIV RNA concentrations did not change significantly during therapy. In vitro neutrophil bactericidal activity against Staphylococcus aureus and superoxide production were not significantly affected by rIFN-γ therapy. We conclude that rIFN-γ therapy in HIV-infected children receiving single-agent antiretroviral therapy is safe and does not produce consistent changes in CD4 + -lymphocyte count, plasma HIV RNA concentration, or in vitro neutrophil function.

Asthma, a major cause of school absenteeism, can be triggered by allergens and irritants in the child's environment. A new measurement tool, the Environmental Observation Checklist (EOC), was developed and piloted for qualitative assessment of indoor asthma triggers (allergens and irritants), adequacy of ventilation, and existing environmental control practices. Seventy-five classrooms in 20 schools from two large urban school districts in Texas were surveyed using the EOC. A Q-TRAK Air Quality Monitor was used to assess indoor carbon dioxide, temperature, and relative humidity, concurrently. The EOC appears to be a useful screening tool for identifying schools in need of intervention.

A Deschildre, I Pin, K El Abd. Allergy. 2014;69(6):784–790 The goal of this study was to evaluate asthma control based on Global Initiative for Asthma (GINA) 2006, National Asthma Education and Prevention Program (NAEPP), Childhood Asthma Control Test (C-ACT), and physician’s assessment (PA). This prospective study included 527 asthmatic children aged 4 to 11 years recruited over an 18-month period at an office visit. Children with a chronic illness in addition to asthma were excluded. Both tertiary pediatric pulmonology …

The P2C2 HIV Study is a prospective natural history study initiated by the National Heart, Lung, and Blood Institute in order to describe the types and incidence of cardiovascular and pulmonary disorders that occur in children with vertically transmitted HIV infection (i.e., transmitted from mother to child in utero or perinatally). This article describes the study design and methods. Patients were recruited from five clinical centers in the United States. The cohort is composed of 205 infants and children enrolled after 28 days of age (Group I) and 612 fetuses and infants of HIV-infected mothers, enrolled prenatally (73%) or postnatally at age

Background Chronic granulomatous disease (CGD) of childhood is a rare congenital abnormality of the phagocyte NADPH oxidase system. Affected neutrophils and macrophages have an ineffective respiratory burst and cannot destroy certain phagocytized bacteria and fungi. CGD patients usually present with recurrent pyogenic and fungal infections. Catalase-positive bacteria are frequently involved, since they metabolize the hydrogen peroxide they produce, making it unavailable for augmentation of microbicidal activity in CGD neutrophils. Afflicted patients also have a tendency to form granulomas, which can lead to obstruction of the gastrointestinal and genitourinary tracts. Methods Charts of 10 patients with CGD were reviewed for age at diagnosis, surgical procedures, complications of these procedures, and medical treatment. Results Eight of the 10 children were male. The average age at first presentation was 18 months (range 2 days to 9.8 years). Each child developed a mean of 9.9 infections and an average of 1.4 infections per year. All required surgical procedures, with an average of 2.9 procedures each. Five children had operative procedures for infections that preceded the diagnosis of CGD. The procedures performed most frequently were incision and drainage of soft-tissue abscesses (7) or perirectal abscess (3), thoracentesis (3), and bronchoscopy (3). Three children had poor wound healing following surgery. Two developed partial gastric outlet obstruction which resolved with antibiotic therapy. One developed granulomatous cystitis with obstruction which responded to antibiotics. Conclusions Since patients with undiagnosed CGD may present with surgical problems, surgeons need to be familiar with this condition. The diagnosis should be suspected in children who have recurrent or unusual infections or unexplained problems with wound healing.

Background The effect of pretransplantation conditioning on the long-term outcomes of patients receiving hematopoietic stem cell transplantation for severe combined immunodeficiency (SCID) has not been completely determined. Objective We sought to assess the outcomes of 23 mostly conditioned patients with SCID and compare their outcomes with those of 25 previously reported nonconditioned patients with SCID who underwent transplantation. Methods In the present study we reviewed the medical records of these 23 consecutive, mostly conditioned patients with SCID who underwent transplantation between 1998 and 2007. Results Eighteen patients (median age at transplantation, 10 months; range, 0.8-108 months) received haploidentical mismatched related donor, matched unrelated donor, or mismatched unrelated donor transplants, 17 of whom received pretransplantation conditioning (with 1 not conditioned); 13 (72%) patients engrafted with donor cells and survive at a median of 3.8 years (range, 1.8-9.8 year); 5 (38%) of 13 patients require intravenous immunoglobulin; and 6 of 6 age-eligible children attend school. Of 5 recipients (median age at transplantation, 7 months; range, 2-23 months) of matched related donor transplants, all 5 engrafted and survive at a median of 7.5 years (range, 1.5-9.5 year), 1 recipient requires intravenous immunoglobulin, and 3 of 3 age-eligible children attend school. Gene mutations were known in 16 cases: mutation in the common γ chain of the IL-2 receptor (IL2RG) in 7 patients, mutation in the α chain of the IL-7 receptor (IL7RA) in 4 patients, mutation in the recombinase-activating gene (RAG1) in 2 patients, adenosine deaminase deficiency (ADA) in 2 patients, and adenylate kinase 2 (AK2) in 1 patient. Early outcomes and quality of life of the previous nonconditioned versus the present conditioned cohorts were not statistically different, but longer-term follow-up is necessary for confirmation. Conclusions Hematopoietic stem cell transplantation in patients with SCID results in engraftment, long-term survival, and a good quality of life for the majority of patients with or without pretransplantation conditioning.

Translating behavioral theories, models, and strategies to guide the development and structure of computer-based health applications is well recognized, although a continued challenge for program developers. A stepped approach to translate behavioral theory in the design of simulations to teach chronic disease management to children is described. This includes the translation steps to: 1) define target behaviors and their determinants, 2) identify theoretical methods to optimize behavioral change, and 3) choose educational strategies to effectively apply these methods and combine these into a cohesive computer-based simulation for health education. Asthma is used to exemplify a chronic health management problem and a computer-based asthma management simulation (Watch, Discover, Think and Act) that has been evaluated and shown to effect asthma self-management in children is used to exemplify the application of theory to practice. Impact and outcome evaluation studies have indicated the effectiveness of these steps in providing increased rigor and accountability, suggesting their utility for educators and developers seeking to apply simulations to enhance self-management behaviors in patients.

AM Karvonen, A Hyvarinen, H Rintala. Allergy. 2014;69(8):1092–1101 The goal of this study was to identify better ways to characterize microbial exposure early in life as a possible predictor of respiratory symptoms and allergies. A birth cohort of 410 children in Finland was recruited over a 3-year period and followed up until 6 years of age. Asthma, wheezing, cough, and atopic dermatitis were assessed by questionnaires administered during the third trimester and in follow-up at ages 2, …

The "Partners in School Asthma Management" program for inner-city elementary school children comprises (1) case finding; (2) linkage of school nurses, parents, and clinicians; (3) a computer-based tailored educational program; and (4) school environmental assessment and intervention. Case finding identified 1730 children in 60 elementary schools with probable asthma; 835 (96% Hispanic or African American) joined the study. Baseline, posttest, and follow-up measures of asthma knowledge, self-efficacy, and self-management behavior were obtained from the children, and data on symptoms, emergency department visits, and hospitalizations were obtained from their parents. The schools provided data on grades and absences. Each school had a baseline and follow-up environmental assessment. The children in the intervention group showed greater increases in knowledge, self-efficacy, and some aspects of self-management. No differences between groups were found in health status variables, school performance, attendance, or levels of environmental allergens in schools. In 15 schools, an enhanced intervention allowed children and their parents to meet with a project physician, develop an asthma action plan, and receive a 1-month supply of medication; the project physician then followed up with the child's community physician. Children participating in this enhanced intervention had better school performance and fewer absences than the comparison group. Overall, the program was effective in improving children's asthma self-management but not in improving their health status. While the case-finding, computer-based self-management training program and linkage system were successfully implemented, the program failed in creating needed changes in the medical (action plans by community physicians) and physical environments (reduced school allergen levels) of the children.

OBJECTIVE. Many children are brought to the pediatric emergency department (ED) with acute asthma symptoms. Emergency asthma care is costly, and many ED visits may be preventable. Families often do not have written asthma action plans and lack asthma self-managment skills. This study tests a tailored self-managment intervention delivered in the ED for families of children with asthma. The primary hypotheses were that the intervention group would have greater confidence to manage asthma 14 days postintervention and more well-asthma visits and fewer urgent care/ED visits at 9 and 12 months. METHODS. This randomized intervention/usual-care study was part of a larger ED asthma surveillance project in 4 urban pediatric ED sites. Asthma educators used a computer-based resource to tailor the intervention messages and provide a customized asthma action plan and educational summary. Children with acute asthma were enrolled during an ED visit, and follow-up telephone interviews were conducted during the next 9 months. The ED clinician classified the child’s acute and chronic severity. RESULTS. To date, 464 subjects aged 1 to 18 years have been enrolled. The ED clinicians reported that 46% had intermittent and 54% had persistent chronic severity with 51% having mild acute severity episodes. The confidence level to prevent asthma episodes and keep them from getting worse was significantly higher in the intervention group at 14 days postintervention. More subjects in the intervention group reported well-asthma visits by 9 months. Return ED visits were significantly lower in the intervention group in those with intermittent asthma. Twelve-month follow-up is in process. CONCLUSIONS. The tailored ED self-management intervention demonstrates significant effects on caregiver self-confidence and well-visit follow-up. Additional evaluation is needed to determine what impact this intervention has long-term.

OBJECTIVE. Our goal was to teach emergency department (ED) physicians how to use standardized criteria for diagnosing and classifying asthma severity and to describe the patterns of pediatric ED utilization of these criteria for classification of both acute and chronic severity. METHOD. A health care provider education module was developed and implemented in 4 participating EDs in southeast Texas to educate ED physicians and health care providers on the diagnosis and acute and chronic severity classification of pediatric asthma patients. We undertook both retrospective (medical chart extraction) and prospective surveillance over a 2-year period of all children presenting to 1 of 4 EDs with acute asthma. Demographic characteristics, classification of severity, health care resource utilization, and primary physician contact information were collected. RESULTS. The health care provider educational intervention was provided for 84 different physicians. A subset of 16 physicians was randomly tested preintervention and postintervention. Mean mock-scenario scores at 2 weeks showed an improvement of 55.6%, which was sustained at retesting at 6 months. Over the 2-year period, 6222 individual pediatric ED encounters were entered into the surveillance database. The median age of presentation was 5 years. More than 32% of the patients in the study were uninsured. The majority of the patients in each category had asthma of mild severity: mild intermittent chronic (58.7%) and mild acute (53.9%). CONCLUSIONS. Physicians who completed a health care provider education module learned to effectively diagnose asthma and recognize standardized acute and chronic severity classifications. The majority of children with asthma who presented to the Texas Emergency Department Asthma Surveillance project's participating EDs were classified as having mild acute severity and mild intermittent chronic disease. Almost one third of these patients did not have health insurance.

Existing guidelines for the clinical management of asthma provide a good framework for such tasks as diagnosing asthma, determining severity, and prescribing pharmacological treatment. Guidance is less explicit, however, about establishing a patient-provider partnership and overcoming barriers to asthma management by patients in a way that can be easily adopted in clinical practice. We report herein the first developmental phase of the "Stop Asthma" expert system. We describe the establishment of a knowledge base related to both the clinical management of asthma and the enhancement of patient and family self-management (including environmental management). The resultant knowledge base comprises 142 multilayered decision rules that describe clinical and behavioral management in three domains: 1) determination of asthma severity and control; 2) pharmacotherapy, including prescription of medicine for chronic maintenance, acute exacerbation, exercise pretreatment, and rhinitis relief; and 3) patient self-management, including the process of intervening to facilitate the patient's asthma medication management, environmental control, and well-visit scheduling. The knowledge base provides a systematic and accessible approach for intervening with family asthma-related behaviors.

Background: Growth failure often precedes secondary infections in HIV-infected infants and children, suggesting that inadequate protein deposition may be an early manifestation of infection by the virus. However, the protein metabolic response elicited by the virus in young children is unknown. Objective: We compared children with HIV infection and agematched children without HIV infection with regard to wholebody and splanchnic protein kinetics and synthesis of acute phase proteins (APPs). Design: Whole-body and splanchnic leucine kinetics and fractional and absolute synthesis rates of 2 positive and 4 negative APPs were measured in 6 asymptomatic, HIV-infected children (4 males and 2 females) aged 6‐17 mo and 4 uninfected children (3 females and 1 male) aged 7‐9 mo who were in the fed state. Results: Compared with the control children, the HIV-infected children had significantly lower dietary energy and protein intakes and leucine balance and significantly faster leucine flux and fractional splanchnic leucine extraction; there was no significant difference between the groups in leucine oxidation rates. The HIVinfected children also had significantly higher plasma concentrations and absolute synthesis rates of the positive APPs and a significantly higher fractional synthesis rate of fibrinogen. The concentrations of 2 of the 4 negative APPs, albumin and HDL apolipoprotein A-I, were significantly lower in the HIV-infected children but were not associated with slower synthesis rates. Conclusions: Children with HIV infection but without secondary infection have reduced protein balance because of an inability to down-regulate protein catabolism. Furthermore, the acute phase protein response elicited by HIV infection is characterized by higher concentrations and synthesis rates of positive APPs without lower concentrations of some negative APPs. Am J Clin Nutr 2003;78:182‐9.