1/75. Occupational asthma and IgE sensitization to cellulase in a textile industry worker.BACKGROUND: Although there have been a few reports of occupational asthma due to cellulase in several occupational settings, this is the first case of cellulase-induced occupational asthma in an employee working in the textile industry. Its pathogenetic mechanism remains to be further clarified. OBJECTIVE: It is important to alert physicians to the possibility of occupational asthma caused by cellulase in workers of the textile industry. methods AND RESULTS: The patient had atopy and strong positive responses to cellulase extract on skin prick tests. Bronchoprovocation test showed an early asthmatic response to cellulase extract. serum specific IgE and specific IgG4 antibodies to cellulase were detected by enzyme-linked immunosorbent assay (ELISA). In order to further characterize the allergenic component of the extract, sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) and electroblotting studies were performed. Eight IgE binding components ranging from 6 to 97.5 kD were detected within the cellulase extract. CONCLUSION: These findings suggest that inhalation of cellulase can induce IgE-mediated bronchoconstrictions in employees working in the textile industry.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/75. Using statistical process control charts for the continual improvement of asthma care.BACKGROUND: Home monitoring of lung function using simple, inexpensive tools to measure peak expiratory flow rate (PEFR) has been possible since the 1970s. Yet although current national and international guidelines recommend monitoring of PEFRs via traditional run charts, their use by both patients and physicians remains low. The role of statistical process control (SPC) theory and charts in the serial monitoring of lung function at home were explored and applied to the direct care of patients with asthma. The method represents an integration of collective professional and improvement knowledge with the related disciplines of continual improvement, SPC, system thinking/system dynamics, paradigms, and the learning community/organization. CASE STUDIES: Use of PEFR control charts for four patients cared for at the asthma-Allergy Clinic and research Center (Shreveport, La) is described. The key to good asthma control is the ability to optimize lung function by reducing the variation between serial lung function measurements and thereby generate a safe range of function. knowledge of the type of variation (special cause or common cause) in the system helps in focusing clinical decision making. Case 4, an 11-year-old boy, for example, shows how control charts were used to learn the effects of a new inhaled corticosteroid. Comparison of the last 14 days of baseline and the last 14 days of open label use of the inhaled corticosteroid showed an obvious improvement in actual PEFR values--which a run chart or comparison of means would have easily demonstrated. The control chart showed that this child's care process at baseline was functionally at risk for severe asthma (46% personal best) and that the effect of the new medication not only elevated the mean function but shifted the range of function from 46%-72% personal best to 78%-102% personal best. At this new range of function the patient's system of care was not capable of delivering values that are at risk for severe asthma. Unless the range of function the change in care is capable of producing is specifically quantitated, misinterpretation of improvement data can occur. DISCUSSION: Developing the concept of the PEFR control chart involved examining and challenging traditional mental models for monitoring PEFR at home in the care of asthma, acquiring a better understanding of the workings of dynamic systems and with system thinking, and sharing what was learned with patients and seeking their input. CONCLUSIONS: The PEFR control chart employs an interesting statistical platform that enables the integration of knowledge of serial measurements and knowledge of the variation between those measurements into a tool with which to better assess the asthma care process being followed. This tool provides clinical insights, practical knowledge, and opportunities unavailable to patients and physicians via traditional PEFR charting.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
3/75. A study on severe food reactions in sweden--is soy protein an underestimated cause of food anaphylaxis?BACKGROUND AND methods: Because of a fatal case of soy anaphylaxis occurring in sweden in 1992, a study was started the following year in which all physicians were asked to report fatal and life-threatening reactions caused by food. The results of the first 3 years of the study are reported here, including results from another ongoing study on deaths from asthma during the same period. RESULTS: In 1993-6, 61 cases of severe reactions to food were reported, five of them fatal. Peanut, soy, and tree nuts seemed to have caused 45 of the 61 reactions, and four of them were fatal. If two cases occurring less than a year before our study started are included, we are aware of two deaths caused by peanuts and four deaths caused by soy. All four youngsters who died from soy anaphylaxis with asthma were severely allergic to peanuts but had no previously known allergy to soy. In most cases, there was a rather symptom-free period for 30-90 min between early mild symptoms and severe and rapidly deteriorating asthma. CONCLUSIONS: Soy has probably been underestimated as a cause of food anaphylaxis. Those at risk seem to be young people with asthma and peanut allergy so severe that they notice symptoms after indirect contact.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/75. Severe steroid-dependent asthma with IgG-2 deficiency and recurrent sinusitis: response to treatment with high-dose intravenous immunoglobulin.patients with severe asthma pose a dilemma to the physician since the treatment they need, namely high doses of oral steroids, has serious side effects, especially among the pediatric population. Deficiency in one or more of the IgG subclasses has been associated with abnormal pulmonary function, as well as with recurrent sinopulmonary infections in adults and children. In the last years attention has been focused on alternative therapies for these patients. One of these alternatives is the treatment with intravenous immunoglobulin (IVIG). We report an 11-year-old boy with severe asthma since the age of two years and multiple hospital admissions due to asthmatic crisis even more frequent and severe, to the point of needing, in the last year, daily treatment with high doses of oral steroids (20 mg). During six months the patient was given high doses of intravenous immunoglobulin. After one month of treatment a clinical and spirometric improvement was apparent allowing to taper down the oral steroids until their complete substitution by inhaled budesonide (1,600 microg/day). The only side effects noted were severe headaches after gammaglobulin infusions which responded well to oral paracetamol. This improvement was sustained throughout the treatment period, but few weeks after the IVIG was suspended the clinical and spirometric parameters started to worsen again.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/75. Leukotriene modifiers and churg-strauss syndrome: adverse effect or response to corticosteroid withdrawal?Zafirlukast, montelukast and pranlukast are all cysteinyl leukotriene receptor antagonists that have recently been approved for the treatment of asthma. Within 6 months of zafirlukast being made available on the market, 8 patients who received the agent for moderate to severe asthma developed eosinophilia, pulmonary infiltrates, cardiomyopathy and other signs of vasculitis; the syndrome that these patients developed was characteristic of the churg-strauss syndrome. All of the patients had discontinued systemic corticosteroid use within 3 months of presentation and all developed the syndrome within 4 months of zafirlukast initiation. The syndrome dramatically improved in each patient upon reinitiation of corticosteroid therapy. Since the initial report, there have been multiple similar cases reported to the relevant pharmaceutical companies and to federal drug regulatory agencies in association with zafirlukast as well as with pranlukast, montelukast, and with use of high doses of inhaled corticosteroids, thus leading to an increased incidence rate of the churg-strauss syndrome. Many potential mechanisms for the association between these drugs and the churg-strauss syndrome have been postulated including: increased syndrome reporting due to bias; potential for allergic drug reaction; and leukotriene imbalance resulting from leukotriene receptor blockade. However, careful analysis of all reported cases suggests that the churg-strauss syndrome develops primarily in those patients taking these asthma medications who had an underlying eosinophilic disorder that was being masked by corticosteroid treatment and unmasked by novel asthma medication-mediated corticosteroid withdrawal, similar to the forme fruste of the churg-strauss syndrome. It remains unclear what the exact mechanism for this syndrome is and whether this represents an absolute increase in cases of vasculitis, but it appears that none of the asthma medications implicated in leading to the development of churg-strauss syndrome was directly causative of the syndrome. These agents remain well tolerated and effective medications for the treatment of asthma, although physicians must be wary for the signs and symptoms of the churg-strauss syndrome, particularly in patients with moderate to severe asthma in whom corticosteroids are tapered.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/75. methylprednisolone anaphylaxis.The exacerbation of asthma is a problem frequently encountered by emergency physicians. In addition to oxygen and beta adrenergic agonists, oral and intravenous corticosteroids are increasingly being used to alleviate bronchospasm and to prevent recurrence of dyspnea. methylprednisolone sodium succinate has been advocated as an intravenous adjunct in the treatment of asthma. We present the case of a steroid-dependent, 17-year-old male asthmatic, who experienced anaphylaxis, with respiratory arrest, within minutes of receiving intravenous methylprednisolone. Our patient rapidly responded to respiratory support and epinephrine. methylprednisolone-induced anaphylaxis is reviewed.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/75. A confidential enquiry into certified asthma deaths in the North of england, 1994-96: influence of co-morbidity and diagnostic inaccuracy.To understand more fully the nature of events leading to asthmatic death, we conducted a confidential enquiry prospectively throughout 1994-96 among the surviving relatives and respective general practitioners of subjects whose deaths could be attributed to asthma, whether wholly or partly. We also reviewed relevant hospital records and autopsy reports, and we submitted all the gathered information to an enquiry panel for evaluation. The subjects were identified from death certificates issued in five districts of the Northern Health Region of england (population 1 million) on which asthma was recorded as the primary cause of death. The enquiry panel agreed that asthma had been a critical factor in causing death in only 33 of the 79 certified cases for which there were sufficient data. The level of concordance was substantially greater for subjects aged < 65 years (76%) than for those who were older (17%). In 16 of the 33 cases asthma alone appeared to be responsible for death, but in 17 cases a wide variety of additional, co-morbid, disorders appeared to have contributed. They included, during the 24 h preceding death, gastric aspiration, septicaemia, a single dose of a beta-blocker, the abuse of organic solvents or illicit drugs and possibly, an inadvertent exposure to horse allergen. More chronic causes of co-morbidity included ischaemic heart disease, chronic obstructive pulmonary disease (COPD), thoracic cage deformity and alcohol abuse. There were possible errors of judgement in two cases by the supervising physician (6%) and in three cases by the patient (9%). Poor compliance and psychosocial disruption probably exerted an additional adverse influence in nine cases (27%). We conclude: (1) that asthma death certification in subjects aged 65 years or more is very unreliable, (2) that for approximately half of the deaths in which asthma exerted a critical role there were critical co-morbid disorders and (3) that errors of judgement, poor compliance, or psychosocial disruption are likely to have exerted an additional adverse influence in an important minority of cases.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/75. Inhaled corticosteroids and churg-strauss syndrome: a report of five cases.churg-strauss syndrome is an eosinophil-associated, small vessel granulomatous vasculitis, characterized by late onset asthma, upper airways disease, eosinophilia, and clinical manifestations of systemic vasculitis. Several cases of churg-strauss syndrome have been recognized in patients treated with cysteinyl leukotriene-receptor antagonists and weaned off systemic corticosteroids. These cases have led to a general warning on the possible development of Churg-Strauss syndrome after taking cysteinyl leukotriene-receptor antagonists. The authors report five cases of churg-strauss syndrome in severe steroid dependent asthmatics in whom inhaled corticosteroids allowed systemic corticosteroid withdrawal. It is concluded that physicians should monitor patients carefully when severe asthma is controlled with any substance allowing withdrawal from (or even avoidance) of systemic corticosteroids. case-control studies should identify more precisely the risk factors of churg-strauss syndrome.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/75. The "Peter Pan" syndrome and allergy practice: facilitating adherence through the use of social support.The complexity of care of some patients in an allergy-immunology practice may be increased by behavioral abnormalities of the patients. Facilitating adherence through the use of social support may be the most effective treatment strategy for some of the most difficult of these patients. We report three patients whose medical management problems were alleviated largely because of the participation of their support system. All three patients were stabilized because of the acceptance of responsibility and support of the physician by the designated member of the patient's support system. The range of social support used to manage nonadherent patients ranged from directly providing instructions to a family member to the consistent presence of a spouse or companion at multiple clinical visits. In all cases, the success in management was attributed largely to the presence of a support system.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/75. alternaria-associated asthma.In addition to house dust mites, there is increasing evidence that mold allergens, especially alternaria, are implicated in contributing to allergic reaction, rhinitis, and asthma indoors. Situations leading to the exacerbation of asthma in an employee were investigated and subsequent medical evaluations were performed. An industrial hygiene study was conducted and bioaerosol testing revealed several mold allergens were present. However, based on the medical evaluation and testing results (skin prick test and radioallergosorbent test [RAST]), it was concluded that alternaria was inducing the respiratory reaction. alternaria was present in the drip pan of the air conditioner unit and remedial actions were taken to remove the mold. Post-remedial bioaerosol sampling results revealed alternaria was no longer present in the air and the employee returned to the office without recurrence of symptoms. Practically, several factors should be considered prior to concluding an association between exposure and illness. First, the employee's symptoms and signs should be consistent with a medical diagnosis. Second, there should be either in vitro or in vivo evidence of exposure. Third, environmental assessment should reveal evidence of plausible biological exposure. Fourth, there should be substantial improvement or even resolution of the illness after appropriate remediation of the health hazard. This case study illustrates the importance of teamwork by industrial hygienists and occupational health physicians in treatment and prevention of occupational and environmental diseases.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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