The information in this report is intended to help health care decisionmakers-patients and clinic... more The information in this report is intended to help health care decisionmakers-patients and clinicians, health system leaders, and policymakers, among others-make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients. This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied. This document is in the public domain and may be used and reprinted without special permission. Citation of the source is appreciated. Persons using assistive technology may not be able to fully access information in this report. For assistance contact [email protected]. None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
International Forum of Allergy & Rhinology, Jun 9, 2018
Background: The purpose of the systematic review is to evaluate the efficacy and safety of sublin... more Background: The purpose of the systematic review is to evaluate the efficacy and safety of sublingual immunotherapy (SLIT) for the treatment of allergic asthma. Methods: PubMed, Embase, and CENTRAL databases were searched, updating an earlier review (January 1, 2005 through May 8, 2017). Randomized, controlled studies (RCTs) were included, which reported one of the prespecified outcomes: asthma symptoms measured by control composite scores; quality of life; medication use; pulmonary physiology; and health-care utilization. For safety outcomes, RCTs and observational studies were included. Two independent reviewers extracted data, assessed risk of bias, and graded strength of evidence (SOE) for each outcome. Results: Fourteen RCTs (n = 2585) assessed the efficacy of SLIT for asthma. The RCTs utilized house dust mite (HDM), birch, or grass allergen. SLIT improved asthma symptoms (high SOE), decreased use of long-term control medication, and improved forced expiratory volume in 1 second (FEV 1) (moderate SOE). SLIT may decrease quick-relief medication use, and improve disease-specific quality of life (low SOE). For safety, 20 RCTs and 10 observational studies (n = 3621) were identified. Local (risk differences ranged from −0.03 to +0.765) and systemic allergic reactions (risk differences ranged from −0.03 to +0.06) were a common occurrence in SLIT and control groups. Life-threatening reactions were uncommon, with 3 cases of anaphylaxis and no deaths reported. Conclusion: There is moderate-to-high strength evidence that SLIT improves allergic asthma symptoms, reduces long-term control medication use, and improves FEV 1 based on studies of HDM, birch, and grass. SLIT rarely is associated with life-threatening adverse events. C 2018 ARS-AAOA, LLC.
Learning Objectives: Post-operative pulmonary complications (PPCs) cause high morbidity, mortalit... more Learning Objectives: Post-operative pulmonary complications (PPCs) cause high morbidity, mortality and healthcare expenditures. Treatment of patients at high risk of PPCs with aggressive pulmonary management may help prevent these complications. The MetaNeb® System is a device that delivers continuous highfrequency oscillation (CHFO) and positive expiratory pressure (CPEP) to facilitate pulmonary mucus clearance and provide lung expansion. The aim of this multiinstitutional prospective trial was to evaluate the impact of MetaNeb® therapy on the rate of PPCs in high-risk surgical patients. Methods: In Phase I, CPT and ICD codes were queried to identify patients who underwent thoracic, upper abdominal, or aortic open surgical procedures at three institutions (n = 210) from December 2014 to April 2016. Patients were randomly selected at each site and screened for age, comorbidities, and ASA score to estimate PPC rates. In Phase II, 207 subjects were enrolled prospectively from the 3 sites over a 9-month period from October 2016 to July 2017 using the same entry criteria. Subjects in the Phase II cohort received treatment with The MetaNeb® System, in addition to standard respiratory therapy. The rate of PPCs, [defined as prolonged mechanical ventilation, prolonged high-level respiratory support, pneumonia, and/or readmission the intensive care unit (ICU) for pulmonary complications] was compared between the two cohorts. We also compared time on ventilator, ICU length of stay (LOS) and hospital LOS using t-tests. Data are mean±SD. Results: There were a total of 417 subjects enrolled. Phase II subjects were more likely to be older (61.1 ± 13.8 vs. 57.4 ± 15.5), male (62.8% vs. 54.8%) and have higher ASA scores (ASA 4&5 24.2% vs. 17.6%). Treatment with MetaNeb® resulted in decreased PPCs from 22.9% (Phase I) to 16.4% (Phase II) (34/207) (p = 0.099). Similarly, MetaNeb® treatment led to reduction in time on ventilator (23.7 ± 107.5 to 8.4 ± 27.5 hours, p < 0.05), ICU LOS (2.1 ± 6.0 to 1.2 ± 2.6 days, p < 0.05) and hospital LOS (8.4 ± 7.9 to 6.8 ± 5.1 days, p < 0.05). Conclusions: Our results suggest that aggressive pulmonary treatment with The MetaNeb® System reduces PPCs and resource use in high-risk patients.
Journal of the American Geriatrics Society, Jul 1, 2003
To determine whether patient age is associated with differences in flexible bronchoscopy techniqu... more To determine whether patient age is associated with differences in flexible bronchoscopy technique and tolerance. DESIGN: Prospective cohort study. SETTING: University hospital system. PARTICIPANTS: One thousand three hundred fifty-eight adults, including 219 (16.1%) aged 70 and older, undergoing bronchoscopy. MEASUREMENTS: Indications, sampling procedures, medication doses, patient reports of pain, willingness to return, and adverse events associated with bronchoscopy. RESULTS: Indications for bronchoscopy varied with age, with solitary pulmonary nodule (P Ͻ .001), mass (P Ͻ .001), or lymphadenopathy (P Ͻ .001) being more common in older patients. Invasive sampling methods were used more often with increasing age, but variation in disease processes between age groups accounted for the difference in sampling method performed. Mean doses of midazolam and fentanyl given for sedation decreased with increasing age (P Ͻ .001). There was no significant difference between older and younger patients in reported very good to excellent pain control (50% of patients Ն 70 vs 64% of patients Ͻ 40; P ϭ .56) or in willingness to return for repeat bronchoscopy (98% vs 92%, respectively; P ϭ .324). Overall risk for an adverse event increased with increasing patient age (P Ͻ .01), but adverse events were uncommon and generally not severe. Hypotension and pneumothorax were rare but occurred more often in older persons (1.9% and 3.4% in patients Ն 70 vs 0.5% and 0.7% in patients Ͻ 40, respectively). CONCLUSION: Despite more-invasive sampling methods and less sedation during bronchoscopy, elderly patients tolerate bronchoscopy as well as younger patients. There is increased risk for adverse events with increasing age, but the absolute frequency is low, suggesting that chronological age should not be a contraindication for bronchoscopy in older persons.
PURPOSE: Chronic mucous hypersecretion is common in moderate-severe COPD and is associated with r... more PURPOSE: Chronic mucous hypersecretion is common in moderate-severe COPD and is associated with respiratory infections and AE-COPD. HFCWO is accomplished using a pneumatic vest to facilitate mucous clearance. We hypothesized that patients using HFCWO therapy would have fewer AE-COPD. METHODS: We conducted a sham-controlled, double-masked parallel group trial (N=50) of HFCWO (30 minutes daily for 12 weeks). Subjects had doctor diagnosed COPD, FEV1/FVC ≤; 70%, ≥ 20 pk-yrs tobacco, age ≥ 45yrs, daily mucous production, ≥ 1 AE-COPD in past 6 mos. The primary outcome was rate of AE-COPD, (modified Winnipeg criteria assessed by weekly interview). RESULTS: Subjects wer64% male, 80% white and means age 63 years. 26 received active HFCWO (A) and 24 received a sham device (S). AE-COPD were common during the12-week follow-up (92% A vs. 95% S, p=.65). The rate of AE-COPD was lower in A than S (4 vs. 5.5/12wks, p<.02 by Poisson regression). By 12-weeks, the % of subjects with daily phlegm production decreased in A (75 to 52%), but increased in S (54 to 67%)(p=.35 for difference). Coughing up phlegm was more likely to become easy or mild in A than S (29 vs. 20%, p=.71). Quality of life (St. George's) improved in both S (p=.02) and A (p=.04), though there were no significant differences between groups (−6 vs. −3, p=.38). Selfreported adherence (daily use) was somewhat lower for A than S (57 vs. 80 %, p=.28). CONCLUSION: This pilot study of active HFCWO therapy showed a significant reduction in the rate of AE-COPD compared with use of a sham device. Although no significant differences were found for symptoms and quality of life, the direction of change suggests a potential treatment effect.
Annals of Allergy Asthma & Immunology, Aug 1, 2004
Background: Although there is evidence that contact with mice is associated with IgE-mediated mou... more Background: Although there is evidence that contact with mice is associated with IgE-mediated mouse sensitization and mouse specific antibody responses, the exposure-response relationships remain unclear. Objective: To determine whether IgE-mediated mouse sensitization and mouse specific IgG (mIgG) and mIgG4 levels increase with increasing Mus m 1 exposure. Methods: One hundred fifty-one workers at a mouse research and production facility were studied. Exposure assignments were made by linking participants to airborne Mus m 1 concentrations in their respective work areas. Cumulative exposure was estimated by multiplying airborne Mus m 1 concentration by duration of employment. Serum mIgG and mIgG4 levels were quantified by antigen-binding assays, and IgE-mediated mouse sensitization was evaluated by skin prick testing (SPT). Results: Prevalence rates of mouse SPT sensitivity and of high levels of mIgG and mIgG4 were increasingly higher by quintiles of increasing cumulative exposure (P Ͻ .01 for SPT, mIgG, and mIgG4). After adjusting for age, sex, and atopy, the log odds ratio (OR) of having positive mouse SPT results was linearly related to cumulative exposure (r 2 ϭ 0.87), as was the log OR of having a high mIgG level (r 2 ϭ 0.86). Quintile of cumulative exposure was an independent predictor of both SPT sensitivity (OR, 1.7; 95% confidence interval, 1.2-2.5) and a high mIgG level (OR, 1.7; 95% confidence interval, 1.2-2.4). Conclusions: IgE-mediated mouse sensitization and mIgG and mIgG4 levels were related to cumulative exposure in a dose-dependent manner. Thus, strategies to prevent allergy to mice should remain focused on reducing mouse allergen exposure.
The Journal of Allergy and Clinical Immunology, Feb 1, 2016
RATIONALE: As cat allergies are associated with severe asthma in children, we sought to determine... more RATIONALE: As cat allergies are associated with severe asthma in children, we sought to determine whether the application of cat dander to barrier-disrupted skin could play a role in the development of allergic asthma. METHODS: In 4-6 week old female mice (BALB/c, C57Bl/6 and mice transgenic for the human HLA DRB1*0401), cat dander extract (CDE) was applied (1.5, 15 or 150 mg) to a shaved area on their back for 10 days after tape stripping. Mice were then administered intranasal challenges of CDE to localize the response to the lungs. Eosinophilia was determined by Wright-Giemsa staining of the bronchoalveolar lavage fluid (BALF) and hematoxylin and eosin staining of lung sections. Airway resistance was measured through a nebulized methacholine challenge. RESULTS: Mice exposed to 15 mg CDE on the skin showed increased eosinophils in the BALF and peribronchial tissue (BALB/c: 2.3 6 1.8 x 10 4 eosinophils and 0.262 6 0.257 eosinophils/mm 2 respectively) compared to naive mice (BALB/c: 0.02 6 0.04 x 10 4 eosinophils in BALF and 0 eosinophils/mm 2 in the peribronchial tissue; p <0.05). Airway resistance was also increased. Intriguingly, eosinophilia and airway resistance were markedly reduced in mice that received 150 mg CDE on the skin (BALB/c: 0.5 6 0.4 x 10 4 eosinophils in BALF and 0.07 6 0.05 eosinophils/mm 2 in the peribronchial tissue). These trends were observed in all three strains. CONCLUSIONS: Although epicutaneous exposure to cat dander on barrier-disrupted skin can lead to allergic airway disease, at a high dose of cat dander on the skin these features of disease are attenuated.
Organophosphate esters (OPE) are flame retardants and plasticizers used in a wide range of consum... more Organophosphate esters (OPE) are flame retardants and plasticizers used in a wide range of consumer products. Despite their widespread use, few studies have characterized pediatric exposures. We assessed variability and predictors of OPE exposures in a cohort panel study of 179 predominantly Black school-aged children in Baltimore City, MD. The study design included up to four seasonal week-long in-home study visits with urine sample collection on days 4 and 7 of each visit (nsamples = 618). We quantified concentrations of 9 urinary OPE biomarkers: bis(2-chloroethyl) phosphate (BCEtp), bis(1-chloro-2-propyl) phosphate, bis(1,3-dichloro-2-propyl) phosphate (BDCPP), di-benzyl phosphate (DBuP), di-benzyl phosphate, di-o-cresylphosphate, di-p-cresylphosphate (DPCP), di-(2-propylheptyl) phthalate (DPHP), 2,3,4,5-tetrabromo benzoic acid. We assessed potential predictors of exposure, including demographic factors, household characteristics, and cleaning behaviors. We calculated Spearman/tetrachoric correlations and intraclass correlation coefficients (ICCs) to examine within-week and seasonal intra-individual variability, respectively. We assessed OPE predictors using linear models for continuous log2 concentrations (BDCPP and DPHP) and logistic models for odds of detection (BCEtP, DBuP, DPCP), with generalized estimating equations to account for repeated measures. For all OPEs, we observed moderate within-week correlations (rs: 0.31-0.63) and weak to moderate seasonal reliability (ICC: 0.18-0.38). BDCPP and DPHP concentrations were higher in the summer compared to other seasons. DPHP concentrations were lower among males than females (%diff: -53.5%; 95% CI: -62.7, -42.0) and among participants spending >12 h/day indoors compared to ≤12 h (%diff: -20.7%; 95% CI: -32.2, -7.3). BDCPP concentrations were lower among children aged 8-10 years compared to 5-7 years (%diff: -39.1%; 95% CI: -55.9, -15.9) and higher among children riding in a vehicle the day of sample collection compared to those who had not (%diff: 28.5%; 95% CI: 3.4, 59.8). This study is the first to characterize within-week and seasonal variability and identify predictors of OPE biomarkers among Black school-aged children with asthma, a historically understudied population.
Objective: To determine how much of the variation in physician group profiling for asthma care ca... more Objective: To determine how much of the variation in physician group profiling for asthma care can be attributed to physician groups and how reliable those profiling indicators are. Study design: Cross-sectional study. Variations attributable to physician groups are presented using the intraclass correlation coefficient (ICC). The reliability of profiling results was determined using the ICC and sample size of the physician group. Participants and settings: Between July 1998 and February 1999, patients with asthma from 20 California physician groups were randomly selected to be surveyed; 2515 patients responded. Main outcome measures: Quality indicators for physician group profiling were (1) National Asthma Education and Prevention Program guideline-based processes of care, including accessibility of asthma care, self-management knowledge about asthma care, use of inhaled bronchodilators, and use of inhaled corticosteroids, and (2) patient outcomes, including satisfaction with asthma care, improvement in health status, and emergency department visits and hospitalizations attributable to asthma. Results: The variations attributable to physician group were small (< 10%) for process and outcome indicators. For process indicators, self-management knowledge had the highest ICC (9.83%), and use of inhaled bronchodilators had the lowest ICC (3.08%). For outcome indicators, satisfaction with asthma care had the highest ICC (9.53%), and hospitalization had the lowest ICC (1.35%). Despite low ICCs, a large sample size per physician group (n = 126) yielded acceptable reliability (> or = 0.80) for most profiling results. Conclusions: The selected indicators for profiling asthma care at the physician group level were generally reliable. Sampling a sufficient number of cases is key to achieving useful results from profiling.
This study aims to determine the impact of physical activity on asthma symptom reporting among ch... more This study aims to determine the impact of physical activity on asthma symptom reporting among children living in an inner city. Among 147 children aged 5-12 years with physician-diagnosed asthma, we assessed asthma symptoms using twice-daily diaries and physical activity using the physical activity questionnaire for children during three 8-day periods (baseline, 3 and 6 months). Linear, logistic, and quasi-poisson regression models were used to determine the association between physical activity and asthma symptoms; adjusting for age, sex, race, BMI, caregiver's education, asthma severity, medication use, and season. A 1-unit increase in PAQ score was significantly associated with reporting more nocturnal symptoms [risk ratio (RR): 1.03; 95% CI 1.00-1.06], daytime symptoms (RR: 1.04; 95% CI 1.00-1.09), being bothered by asthma (RR: 1.05; 95% CI 1.00-1.09), and trouble breathing (RR: 1.05; 95% CI 1.00-1.10). Level of physical activity should be taken into account in clinical management of asthma and epidemiological studies of asthma symptom burden.
Background: Allergic rhinitis (AR), also known as hay fever, is caused by an overreaction of the ... more Background: Allergic rhinitis (AR), also known as hay fever, is caused by an overreaction of the immune system to airborne allergens. AR is a substantial cause of widespread morbidity, medical treatment costs, and reduced productivity at work and school. Objective: The goal of this research was to describe patient characteristics and prescription fill patterns for patients with AR and to determine those factors associated with the use of montelukast in a large population of commercially insured patients who sought medical treatment for AR. Methods: This was a retrospective cohort study using administrative claims data from a commercially available database. Patients, aged 4 to 64 years, with ≥3 years' continuous enrollment and ≥1 medical claim for AR between January 1, 2004, and December 31, 2006, were included. Patients with a concomitant asthma diagnosis were excluded. Patients' demographic and clinical characteristics, comorbidities, health care resource utilization, AR-related medication use, and AR-related physician office visits were assessed for 12 months before the first AR medication fill (index) in 2006. Stepwise logistic regression was used to identify factors predicting the initiation of montelukast therapy for the treatment of AR in 2006. Results: The study population consisted of 75,140 children (mean [SD] age, 10.6 [4.0] years) and 226,236 adults (mean age, 43.8 [11.8] years). Slightly more than half (52.4%) of the pediatric population was male compared with 44.7% of the adult population. Fifty percent of patients had no pharmacy fills for an AR medication in 2006. Among patients with AR pharmacy fills (n = 150,751), 78.1% had a single index medication fill (montelukast represented 4.5%) and 21.9% were prescribed multiple index medications. Children with AR were more likely to fill a prescription for montelukast (n = 7513) if they were 4 to 11 years of age; male; diagnosed with cough/wheeze; and had 1 or 2 oral corticosteroid fills, ≥3 antibiotic fills, and AR-related physician office visits in the prior 12 months (all, P < 0.001). Prescription fills for montelukast among adult patients with AR were significantly (P < 0.001) associated with other respiratory/atopic conditions; prior fills for antihistamines, oral corticosteroids, or intranasal corticosteroids; and AR-related physician office visits in the prior 12 months. Children and adults with health plans based in the midwestern or southern region of the United States had greater odds of initiating montelukast than those with plans based in the western region (P < 0.001). Conclusions: Half of the patients identified with AR did not fill a prescription for an AR medication. Among those patients with AR-related prescription drug fills, most were prescribed a single index pharmacotherapy and did not receive additional AR medications within 30 days of the index date. The use of montelukast was limited and was more commonly prescribed to children and adults with AR whose condition was not controlled with other AR medications.
Rationale Evidence from observational studies and to a lesser extent clinical trials suggest that... more Rationale Evidence from observational studies and to a lesser extent clinical trials suggest that a healthy diet may improve symptoms and lung function in patients with asthma. We conducted a pilot study to determine the feasibility of conducting a larger scale dietary trial and to provide preliminary evidence on the impact of a healthy diet on asthma outcomes. Methods In a randomized, two period cross-over trial, participants with asthma received a 4-week dietary intervention followed by a usual diet (or vice versa), separated by a 4-week washout. The dietary intervention was a healthy diet rich in unsaturated fat. During the dietary intervention, participants ate three meals per week on site at the Johns Hopkins ProHealth Research Center. All remaining meals and snacks were provided for participants to consume off-site. During the control diet, participants were instructed to continue their usual dietary intake. Relevant biomarkers and asthma clinical outcomes were assessed at 0, 2, and 4 weeks after starting each arm of the study. Results Eleven participants were randomized, and seven completed the full study protocol. Among these seven participants, average age was 42 years, six were female, and six were African American. Participant self-report of dietary intake revealed significant increases in fruit, vegetable, and omega-3 fatty acid intake with the dietary intervention compared to usual diet. Serum carotenoids (eg. lutein and beta-cryptoxanthin) increased in the intervention versus control. Total cholesterol decreased in the intervention versus control diet. There was no consistent effect on asthma outcomes.
W ith the growth of managed care and health care costs, quality of care has become a major concer... more W ith the growth of managed care and health care costs, quality of care has become a major concern to payers and patients in the United States and worldwide. Performance measurement has the potential to increase provider accountability to patients, encourage health care managers to monitor and improve quality of care, and help consumers to choose providers or health plans. An increasing amount of informa
Due to global climate change, climatologists anticipate not only a rise in mean yearly ambient te... more Due to global climate change, climatologists anticipate not only a rise in mean yearly ambient temperature, but also an increase in the frequency and intensity of variable weather patterns, including extreme hot and cold weather events [1, 2]. Overall mortality is higher during winter months [3, 4] and half of excessive deaths in the cold season are respiratory in nature [5]. Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide and is linked to high healthcare-associated financial burden [6, 7]. Identifying environmental factors that contribute to COPD morbidity is crucial to define adaptive strategies to improve outcomes. Individuals with COPD face increased mortality, higher rates of hospitalisation and exacerbation, and worse quality of life in cold weather seasons [8-10]. It has been difficult to isolate the specific effect of cold temperature from seasonal effects, and little is known about how fluctuations in cold temperature may impact respiratory health among individuals with COPD. We assessed individuals with COPD during the cold season to determine the effect of daily temperature on disease-specific respiratory health outcomes, including daily symptoms, lung function and rescue inhaler use.
The Journal of Allergy and Clinical Immunology: In Practice, Jul 1, 2019
Background: Indoor fine particulate air pollution (PM 2.5) is linked to asthma morbidity; however... more Background: Indoor fine particulate air pollution (PM 2.5) is linked to asthma morbidity; however, whether vitamin D status influences individual susceptibility to airborne exposures is unclear. Objective: We aimed to determine if vitamin D modifies effects of indoor PM 2.5 upon asthma symptoms in urban children. Methods: 120 children aged 5-12 years with physician-diagnosed asthma were evaluated at baseline and every 3 months for 9 months. Indoor PM 2.5 , serum 25-hydroxy vitamin D (25-OH D) levels and asthma symptoms were simultaneously assessed at each time point. Adjusting for confounders, generalized estimating equations assessed 3-way interaction effects of 25-OH D, obesity and PM upon asthma symptoms. Results: Children were of mean (SD) age 9.7 (2.2) years, 36% were obese, and 95% selfreported black race. Mean (SD) PM 2.5 indoor exposure was 38.2 (42.9) μg/m 3 and 25-OH D was 19.1 (7.5) ng/ml. Three-way interaction models demonstrated significantly greater PM 2.5associated effects on daytime asthma symptoms only among obese children with low 25-OH D levels (OR PM2.5 =1.26,p =0.049 at vitamin D=15.5 ng/ml, increasingly stronger PM effects at levels<15.5 ng/ml). In homes with increased PM 2.5 , higher 25-OH D was associated with decreased symptom odds (e.g., OR Vitamin D = 0.87; p=0.049 at PM 2.5 = 52.5 μg/m 3 , increasingly protective effects >52.5 μg/m 3) among obese children. Conclusion: Among obese urban children with asthma, low individual 25-OH vitamin D enhanced adverse respiratory effects associated with indoor PM 2.5. In high PM 2.5 environments,
The information in this report is intended to help health care decisionmakers-patients and clinic... more The information in this report is intended to help health care decisionmakers-patients and clinicians, health system leaders, and policymakers, among others-make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients. This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied. This document is in the public domain and may be used and reprinted without special permission. Citation of the source is appreciated. Persons using assistive technology may not be able to fully access information in this report. For assistance contact [email protected]. None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
International Forum of Allergy & Rhinology, Jun 9, 2018
Background: The purpose of the systematic review is to evaluate the efficacy and safety of sublin... more Background: The purpose of the systematic review is to evaluate the efficacy and safety of sublingual immunotherapy (SLIT) for the treatment of allergic asthma. Methods: PubMed, Embase, and CENTRAL databases were searched, updating an earlier review (January 1, 2005 through May 8, 2017). Randomized, controlled studies (RCTs) were included, which reported one of the prespecified outcomes: asthma symptoms measured by control composite scores; quality of life; medication use; pulmonary physiology; and health-care utilization. For safety outcomes, RCTs and observational studies were included. Two independent reviewers extracted data, assessed risk of bias, and graded strength of evidence (SOE) for each outcome. Results: Fourteen RCTs (n = 2585) assessed the efficacy of SLIT for asthma. The RCTs utilized house dust mite (HDM), birch, or grass allergen. SLIT improved asthma symptoms (high SOE), decreased use of long-term control medication, and improved forced expiratory volume in 1 second (FEV 1) (moderate SOE). SLIT may decrease quick-relief medication use, and improve disease-specific quality of life (low SOE). For safety, 20 RCTs and 10 observational studies (n = 3621) were identified. Local (risk differences ranged from −0.03 to +0.765) and systemic allergic reactions (risk differences ranged from −0.03 to +0.06) were a common occurrence in SLIT and control groups. Life-threatening reactions were uncommon, with 3 cases of anaphylaxis and no deaths reported. Conclusion: There is moderate-to-high strength evidence that SLIT improves allergic asthma symptoms, reduces long-term control medication use, and improves FEV 1 based on studies of HDM, birch, and grass. SLIT rarely is associated with life-threatening adverse events. C 2018 ARS-AAOA, LLC.
Learning Objectives: Post-operative pulmonary complications (PPCs) cause high morbidity, mortalit... more Learning Objectives: Post-operative pulmonary complications (PPCs) cause high morbidity, mortality and healthcare expenditures. Treatment of patients at high risk of PPCs with aggressive pulmonary management may help prevent these complications. The MetaNeb® System is a device that delivers continuous highfrequency oscillation (CHFO) and positive expiratory pressure (CPEP) to facilitate pulmonary mucus clearance and provide lung expansion. The aim of this multiinstitutional prospective trial was to evaluate the impact of MetaNeb® therapy on the rate of PPCs in high-risk surgical patients. Methods: In Phase I, CPT and ICD codes were queried to identify patients who underwent thoracic, upper abdominal, or aortic open surgical procedures at three institutions (n = 210) from December 2014 to April 2016. Patients were randomly selected at each site and screened for age, comorbidities, and ASA score to estimate PPC rates. In Phase II, 207 subjects were enrolled prospectively from the 3 sites over a 9-month period from October 2016 to July 2017 using the same entry criteria. Subjects in the Phase II cohort received treatment with The MetaNeb® System, in addition to standard respiratory therapy. The rate of PPCs, [defined as prolonged mechanical ventilation, prolonged high-level respiratory support, pneumonia, and/or readmission the intensive care unit (ICU) for pulmonary complications] was compared between the two cohorts. We also compared time on ventilator, ICU length of stay (LOS) and hospital LOS using t-tests. Data are mean±SD. Results: There were a total of 417 subjects enrolled. Phase II subjects were more likely to be older (61.1 ± 13.8 vs. 57.4 ± 15.5), male (62.8% vs. 54.8%) and have higher ASA scores (ASA 4&5 24.2% vs. 17.6%). Treatment with MetaNeb® resulted in decreased PPCs from 22.9% (Phase I) to 16.4% (Phase II) (34/207) (p = 0.099). Similarly, MetaNeb® treatment led to reduction in time on ventilator (23.7 ± 107.5 to 8.4 ± 27.5 hours, p < 0.05), ICU LOS (2.1 ± 6.0 to 1.2 ± 2.6 days, p < 0.05) and hospital LOS (8.4 ± 7.9 to 6.8 ± 5.1 days, p < 0.05). Conclusions: Our results suggest that aggressive pulmonary treatment with The MetaNeb® System reduces PPCs and resource use in high-risk patients.
Journal of the American Geriatrics Society, Jul 1, 2003
To determine whether patient age is associated with differences in flexible bronchoscopy techniqu... more To determine whether patient age is associated with differences in flexible bronchoscopy technique and tolerance. DESIGN: Prospective cohort study. SETTING: University hospital system. PARTICIPANTS: One thousand three hundred fifty-eight adults, including 219 (16.1%) aged 70 and older, undergoing bronchoscopy. MEASUREMENTS: Indications, sampling procedures, medication doses, patient reports of pain, willingness to return, and adverse events associated with bronchoscopy. RESULTS: Indications for bronchoscopy varied with age, with solitary pulmonary nodule (P Ͻ .001), mass (P Ͻ .001), or lymphadenopathy (P Ͻ .001) being more common in older patients. Invasive sampling methods were used more often with increasing age, but variation in disease processes between age groups accounted for the difference in sampling method performed. Mean doses of midazolam and fentanyl given for sedation decreased with increasing age (P Ͻ .001). There was no significant difference between older and younger patients in reported very good to excellent pain control (50% of patients Ն 70 vs 64% of patients Ͻ 40; P ϭ .56) or in willingness to return for repeat bronchoscopy (98% vs 92%, respectively; P ϭ .324). Overall risk for an adverse event increased with increasing patient age (P Ͻ .01), but adverse events were uncommon and generally not severe. Hypotension and pneumothorax were rare but occurred more often in older persons (1.9% and 3.4% in patients Ն 70 vs 0.5% and 0.7% in patients Ͻ 40, respectively). CONCLUSION: Despite more-invasive sampling methods and less sedation during bronchoscopy, elderly patients tolerate bronchoscopy as well as younger patients. There is increased risk for adverse events with increasing age, but the absolute frequency is low, suggesting that chronological age should not be a contraindication for bronchoscopy in older persons.
PURPOSE: Chronic mucous hypersecretion is common in moderate-severe COPD and is associated with r... more PURPOSE: Chronic mucous hypersecretion is common in moderate-severe COPD and is associated with respiratory infections and AE-COPD. HFCWO is accomplished using a pneumatic vest to facilitate mucous clearance. We hypothesized that patients using HFCWO therapy would have fewer AE-COPD. METHODS: We conducted a sham-controlled, double-masked parallel group trial (N=50) of HFCWO (30 minutes daily for 12 weeks). Subjects had doctor diagnosed COPD, FEV1/FVC ≤; 70%, ≥ 20 pk-yrs tobacco, age ≥ 45yrs, daily mucous production, ≥ 1 AE-COPD in past 6 mos. The primary outcome was rate of AE-COPD, (modified Winnipeg criteria assessed by weekly interview). RESULTS: Subjects wer64% male, 80% white and means age 63 years. 26 received active HFCWO (A) and 24 received a sham device (S). AE-COPD were common during the12-week follow-up (92% A vs. 95% S, p=.65). The rate of AE-COPD was lower in A than S (4 vs. 5.5/12wks, p<.02 by Poisson regression). By 12-weeks, the % of subjects with daily phlegm production decreased in A (75 to 52%), but increased in S (54 to 67%)(p=.35 for difference). Coughing up phlegm was more likely to become easy or mild in A than S (29 vs. 20%, p=.71). Quality of life (St. George's) improved in both S (p=.02) and A (p=.04), though there were no significant differences between groups (−6 vs. −3, p=.38). Selfreported adherence (daily use) was somewhat lower for A than S (57 vs. 80 %, p=.28). CONCLUSION: This pilot study of active HFCWO therapy showed a significant reduction in the rate of AE-COPD compared with use of a sham device. Although no significant differences were found for symptoms and quality of life, the direction of change suggests a potential treatment effect.
Annals of Allergy Asthma & Immunology, Aug 1, 2004
Background: Although there is evidence that contact with mice is associated with IgE-mediated mou... more Background: Although there is evidence that contact with mice is associated with IgE-mediated mouse sensitization and mouse specific antibody responses, the exposure-response relationships remain unclear. Objective: To determine whether IgE-mediated mouse sensitization and mouse specific IgG (mIgG) and mIgG4 levels increase with increasing Mus m 1 exposure. Methods: One hundred fifty-one workers at a mouse research and production facility were studied. Exposure assignments were made by linking participants to airborne Mus m 1 concentrations in their respective work areas. Cumulative exposure was estimated by multiplying airborne Mus m 1 concentration by duration of employment. Serum mIgG and mIgG4 levels were quantified by antigen-binding assays, and IgE-mediated mouse sensitization was evaluated by skin prick testing (SPT). Results: Prevalence rates of mouse SPT sensitivity and of high levels of mIgG and mIgG4 were increasingly higher by quintiles of increasing cumulative exposure (P Ͻ .01 for SPT, mIgG, and mIgG4). After adjusting for age, sex, and atopy, the log odds ratio (OR) of having positive mouse SPT results was linearly related to cumulative exposure (r 2 ϭ 0.87), as was the log OR of having a high mIgG level (r 2 ϭ 0.86). Quintile of cumulative exposure was an independent predictor of both SPT sensitivity (OR, 1.7; 95% confidence interval, 1.2-2.5) and a high mIgG level (OR, 1.7; 95% confidence interval, 1.2-2.4). Conclusions: IgE-mediated mouse sensitization and mIgG and mIgG4 levels were related to cumulative exposure in a dose-dependent manner. Thus, strategies to prevent allergy to mice should remain focused on reducing mouse allergen exposure.
The Journal of Allergy and Clinical Immunology, Feb 1, 2016
RATIONALE: As cat allergies are associated with severe asthma in children, we sought to determine... more RATIONALE: As cat allergies are associated with severe asthma in children, we sought to determine whether the application of cat dander to barrier-disrupted skin could play a role in the development of allergic asthma. METHODS: In 4-6 week old female mice (BALB/c, C57Bl/6 and mice transgenic for the human HLA DRB1*0401), cat dander extract (CDE) was applied (1.5, 15 or 150 mg) to a shaved area on their back for 10 days after tape stripping. Mice were then administered intranasal challenges of CDE to localize the response to the lungs. Eosinophilia was determined by Wright-Giemsa staining of the bronchoalveolar lavage fluid (BALF) and hematoxylin and eosin staining of lung sections. Airway resistance was measured through a nebulized methacholine challenge. RESULTS: Mice exposed to 15 mg CDE on the skin showed increased eosinophils in the BALF and peribronchial tissue (BALB/c: 2.3 6 1.8 x 10 4 eosinophils and 0.262 6 0.257 eosinophils/mm 2 respectively) compared to naive mice (BALB/c: 0.02 6 0.04 x 10 4 eosinophils in BALF and 0 eosinophils/mm 2 in the peribronchial tissue; p <0.05). Airway resistance was also increased. Intriguingly, eosinophilia and airway resistance were markedly reduced in mice that received 150 mg CDE on the skin (BALB/c: 0.5 6 0.4 x 10 4 eosinophils in BALF and 0.07 6 0.05 eosinophils/mm 2 in the peribronchial tissue). These trends were observed in all three strains. CONCLUSIONS: Although epicutaneous exposure to cat dander on barrier-disrupted skin can lead to allergic airway disease, at a high dose of cat dander on the skin these features of disease are attenuated.
Organophosphate esters (OPE) are flame retardants and plasticizers used in a wide range of consum... more Organophosphate esters (OPE) are flame retardants and plasticizers used in a wide range of consumer products. Despite their widespread use, few studies have characterized pediatric exposures. We assessed variability and predictors of OPE exposures in a cohort panel study of 179 predominantly Black school-aged children in Baltimore City, MD. The study design included up to four seasonal week-long in-home study visits with urine sample collection on days 4 and 7 of each visit (nsamples = 618). We quantified concentrations of 9 urinary OPE biomarkers: bis(2-chloroethyl) phosphate (BCEtp), bis(1-chloro-2-propyl) phosphate, bis(1,3-dichloro-2-propyl) phosphate (BDCPP), di-benzyl phosphate (DBuP), di-benzyl phosphate, di-o-cresylphosphate, di-p-cresylphosphate (DPCP), di-(2-propylheptyl) phthalate (DPHP), 2,3,4,5-tetrabromo benzoic acid. We assessed potential predictors of exposure, including demographic factors, household characteristics, and cleaning behaviors. We calculated Spearman/tetrachoric correlations and intraclass correlation coefficients (ICCs) to examine within-week and seasonal intra-individual variability, respectively. We assessed OPE predictors using linear models for continuous log2 concentrations (BDCPP and DPHP) and logistic models for odds of detection (BCEtP, DBuP, DPCP), with generalized estimating equations to account for repeated measures. For all OPEs, we observed moderate within-week correlations (rs: 0.31-0.63) and weak to moderate seasonal reliability (ICC: 0.18-0.38). BDCPP and DPHP concentrations were higher in the summer compared to other seasons. DPHP concentrations were lower among males than females (%diff: -53.5%; 95% CI: -62.7, -42.0) and among participants spending >12 h/day indoors compared to ≤12 h (%diff: -20.7%; 95% CI: -32.2, -7.3). BDCPP concentrations were lower among children aged 8-10 years compared to 5-7 years (%diff: -39.1%; 95% CI: -55.9, -15.9) and higher among children riding in a vehicle the day of sample collection compared to those who had not (%diff: 28.5%; 95% CI: 3.4, 59.8). This study is the first to characterize within-week and seasonal variability and identify predictors of OPE biomarkers among Black school-aged children with asthma, a historically understudied population.
Objective: To determine how much of the variation in physician group profiling for asthma care ca... more Objective: To determine how much of the variation in physician group profiling for asthma care can be attributed to physician groups and how reliable those profiling indicators are. Study design: Cross-sectional study. Variations attributable to physician groups are presented using the intraclass correlation coefficient (ICC). The reliability of profiling results was determined using the ICC and sample size of the physician group. Participants and settings: Between July 1998 and February 1999, patients with asthma from 20 California physician groups were randomly selected to be surveyed; 2515 patients responded. Main outcome measures: Quality indicators for physician group profiling were (1) National Asthma Education and Prevention Program guideline-based processes of care, including accessibility of asthma care, self-management knowledge about asthma care, use of inhaled bronchodilators, and use of inhaled corticosteroids, and (2) patient outcomes, including satisfaction with asthma care, improvement in health status, and emergency department visits and hospitalizations attributable to asthma. Results: The variations attributable to physician group were small (< 10%) for process and outcome indicators. For process indicators, self-management knowledge had the highest ICC (9.83%), and use of inhaled bronchodilators had the lowest ICC (3.08%). For outcome indicators, satisfaction with asthma care had the highest ICC (9.53%), and hospitalization had the lowest ICC (1.35%). Despite low ICCs, a large sample size per physician group (n = 126) yielded acceptable reliability (> or = 0.80) for most profiling results. Conclusions: The selected indicators for profiling asthma care at the physician group level were generally reliable. Sampling a sufficient number of cases is key to achieving useful results from profiling.
This study aims to determine the impact of physical activity on asthma symptom reporting among ch... more This study aims to determine the impact of physical activity on asthma symptom reporting among children living in an inner city. Among 147 children aged 5-12 years with physician-diagnosed asthma, we assessed asthma symptoms using twice-daily diaries and physical activity using the physical activity questionnaire for children during three 8-day periods (baseline, 3 and 6 months). Linear, logistic, and quasi-poisson regression models were used to determine the association between physical activity and asthma symptoms; adjusting for age, sex, race, BMI, caregiver's education, asthma severity, medication use, and season. A 1-unit increase in PAQ score was significantly associated with reporting more nocturnal symptoms [risk ratio (RR): 1.03; 95% CI 1.00-1.06], daytime symptoms (RR: 1.04; 95% CI 1.00-1.09), being bothered by asthma (RR: 1.05; 95% CI 1.00-1.09), and trouble breathing (RR: 1.05; 95% CI 1.00-1.10). Level of physical activity should be taken into account in clinical management of asthma and epidemiological studies of asthma symptom burden.
Background: Allergic rhinitis (AR), also known as hay fever, is caused by an overreaction of the ... more Background: Allergic rhinitis (AR), also known as hay fever, is caused by an overreaction of the immune system to airborne allergens. AR is a substantial cause of widespread morbidity, medical treatment costs, and reduced productivity at work and school. Objective: The goal of this research was to describe patient characteristics and prescription fill patterns for patients with AR and to determine those factors associated with the use of montelukast in a large population of commercially insured patients who sought medical treatment for AR. Methods: This was a retrospective cohort study using administrative claims data from a commercially available database. Patients, aged 4 to 64 years, with ≥3 years' continuous enrollment and ≥1 medical claim for AR between January 1, 2004, and December 31, 2006, were included. Patients with a concomitant asthma diagnosis were excluded. Patients' demographic and clinical characteristics, comorbidities, health care resource utilization, AR-related medication use, and AR-related physician office visits were assessed for 12 months before the first AR medication fill (index) in 2006. Stepwise logistic regression was used to identify factors predicting the initiation of montelukast therapy for the treatment of AR in 2006. Results: The study population consisted of 75,140 children (mean [SD] age, 10.6 [4.0] years) and 226,236 adults (mean age, 43.8 [11.8] years). Slightly more than half (52.4%) of the pediatric population was male compared with 44.7% of the adult population. Fifty percent of patients had no pharmacy fills for an AR medication in 2006. Among patients with AR pharmacy fills (n = 150,751), 78.1% had a single index medication fill (montelukast represented 4.5%) and 21.9% were prescribed multiple index medications. Children with AR were more likely to fill a prescription for montelukast (n = 7513) if they were 4 to 11 years of age; male; diagnosed with cough/wheeze; and had 1 or 2 oral corticosteroid fills, ≥3 antibiotic fills, and AR-related physician office visits in the prior 12 months (all, P < 0.001). Prescription fills for montelukast among adult patients with AR were significantly (P < 0.001) associated with other respiratory/atopic conditions; prior fills for antihistamines, oral corticosteroids, or intranasal corticosteroids; and AR-related physician office visits in the prior 12 months. Children and adults with health plans based in the midwestern or southern region of the United States had greater odds of initiating montelukast than those with plans based in the western region (P < 0.001). Conclusions: Half of the patients identified with AR did not fill a prescription for an AR medication. Among those patients with AR-related prescription drug fills, most were prescribed a single index pharmacotherapy and did not receive additional AR medications within 30 days of the index date. The use of montelukast was limited and was more commonly prescribed to children and adults with AR whose condition was not controlled with other AR medications.
Rationale Evidence from observational studies and to a lesser extent clinical trials suggest that... more Rationale Evidence from observational studies and to a lesser extent clinical trials suggest that a healthy diet may improve symptoms and lung function in patients with asthma. We conducted a pilot study to determine the feasibility of conducting a larger scale dietary trial and to provide preliminary evidence on the impact of a healthy diet on asthma outcomes. Methods In a randomized, two period cross-over trial, participants with asthma received a 4-week dietary intervention followed by a usual diet (or vice versa), separated by a 4-week washout. The dietary intervention was a healthy diet rich in unsaturated fat. During the dietary intervention, participants ate three meals per week on site at the Johns Hopkins ProHealth Research Center. All remaining meals and snacks were provided for participants to consume off-site. During the control diet, participants were instructed to continue their usual dietary intake. Relevant biomarkers and asthma clinical outcomes were assessed at 0, 2, and 4 weeks after starting each arm of the study. Results Eleven participants were randomized, and seven completed the full study protocol. Among these seven participants, average age was 42 years, six were female, and six were African American. Participant self-report of dietary intake revealed significant increases in fruit, vegetable, and omega-3 fatty acid intake with the dietary intervention compared to usual diet. Serum carotenoids (eg. lutein and beta-cryptoxanthin) increased in the intervention versus control. Total cholesterol decreased in the intervention versus control diet. There was no consistent effect on asthma outcomes.
W ith the growth of managed care and health care costs, quality of care has become a major concer... more W ith the growth of managed care and health care costs, quality of care has become a major concern to payers and patients in the United States and worldwide. Performance measurement has the potential to increase provider accountability to patients, encourage health care managers to monitor and improve quality of care, and help consumers to choose providers or health plans. An increasing amount of informa
Due to global climate change, climatologists anticipate not only a rise in mean yearly ambient te... more Due to global climate change, climatologists anticipate not only a rise in mean yearly ambient temperature, but also an increase in the frequency and intensity of variable weather patterns, including extreme hot and cold weather events [1, 2]. Overall mortality is higher during winter months [3, 4] and half of excessive deaths in the cold season are respiratory in nature [5]. Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide and is linked to high healthcare-associated financial burden [6, 7]. Identifying environmental factors that contribute to COPD morbidity is crucial to define adaptive strategies to improve outcomes. Individuals with COPD face increased mortality, higher rates of hospitalisation and exacerbation, and worse quality of life in cold weather seasons [8-10]. It has been difficult to isolate the specific effect of cold temperature from seasonal effects, and little is known about how fluctuations in cold temperature may impact respiratory health among individuals with COPD. We assessed individuals with COPD during the cold season to determine the effect of daily temperature on disease-specific respiratory health outcomes, including daily symptoms, lung function and rescue inhaler use.
The Journal of Allergy and Clinical Immunology: In Practice, Jul 1, 2019
Background: Indoor fine particulate air pollution (PM 2.5) is linked to asthma morbidity; however... more Background: Indoor fine particulate air pollution (PM 2.5) is linked to asthma morbidity; however, whether vitamin D status influences individual susceptibility to airborne exposures is unclear. Objective: We aimed to determine if vitamin D modifies effects of indoor PM 2.5 upon asthma symptoms in urban children. Methods: 120 children aged 5-12 years with physician-diagnosed asthma were evaluated at baseline and every 3 months for 9 months. Indoor PM 2.5 , serum 25-hydroxy vitamin D (25-OH D) levels and asthma symptoms were simultaneously assessed at each time point. Adjusting for confounders, generalized estimating equations assessed 3-way interaction effects of 25-OH D, obesity and PM upon asthma symptoms. Results: Children were of mean (SD) age 9.7 (2.2) years, 36% were obese, and 95% selfreported black race. Mean (SD) PM 2.5 indoor exposure was 38.2 (42.9) μg/m 3 and 25-OH D was 19.1 (7.5) ng/ml. Three-way interaction models demonstrated significantly greater PM 2.5associated effects on daytime asthma symptoms only among obese children with low 25-OH D levels (OR PM2.5 =1.26,p =0.049 at vitamin D=15.5 ng/ml, increasingly stronger PM effects at levels<15.5 ng/ml). In homes with increased PM 2.5 , higher 25-OH D was associated with decreased symptom odds (e.g., OR Vitamin D = 0.87; p=0.049 at PM 2.5 = 52.5 μg/m 3 , increasingly protective effects >52.5 μg/m 3) among obese children. Conclusion: Among obese urban children with asthma, low individual 25-OH vitamin D enhanced adverse respiratory effects associated with indoor PM 2.5. In high PM 2.5 environments,
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Papers by Gregory Diette