January 2006 World Medical Journal Review
Reviewed by Richard F. Lockey, M.D., Editor-In-Chief
1. TREATING ACUTE RHINOSINUSITIS – EFFICACY OF MOMETASONE FUROATE NASAL SPRAY, AMOXICILLIN, OR PLACEBO
Subjects ( > 12 years; n = 981) were randomized to mometasone furate (MFNS) 200 µg once or twice daily for 15 days, amoxicillin 500 mg TID for 10 days, or respective placebo. MFNS 200 mg BID was superior to both placebo (P <.001) and amoxicillin (P <.002) at improving the major symptom score. This improvement was noted at 2 days and throughout treatment. Likewise, the global response was significantly greater with MFNS 200 µg BID vs. amoxicillin (P = .013) and placebo (P = .001). Editor's comment: MFNS 200 mg twice daily monotherapy is an effective treatment for acute rhinosinusitis associated with an URI. Meltzer EO, et al. J Allergy Clin Immunol 2005; 116:1289
2. SYSTEMIC AND UPPER AND LOWER AIRWAY INFLAMMATION AND EXACERBATION OF COPD
Sputum, nasal wash and serum samples from 41 subjects with COPD exacerbations were analyzed for pathogenic microorganisms and inflammatory markers and were compared to subjects with stable COPD. COPD exacerbation is associated with greater nasal, sputum, and serum inflammation than controls. The degree of upper airway inflammation correlated with the degree of lower airway inflammation. The degree of systemic inflammation correlated with the degree of lower airway inflammation and was greater in the presence of a sputum bacterial pathogen. The authors conclude that exacerbation of COPD is a pan-airway inflammatory process which may account for complications associated with COPD exacerbation. Editor's comment: As in asthma, airway inflammation is united in COPD. Hurst JR, et al. Am J Respir Crit Care Med 2006; 173:71
3. CLINICAL EFFECTS OF PROBIOTICS IN CHILDREN 6 TO 18 MONTHS WITH ATOPIC DERMATITIS
In a previous study (DBPC), these authors reported that the administration of 1 X 109 Lactobacillus fermentum twice daily for 8 weeks compared to placebo resulted in significant clinical improvement in very young children with moderate to severe atopic dermatitis (AD). These same investigators now report that such treatment relative to baseline levels of response is associated with significant increases in T-helper type 1 (Th1-type) cytokine IFN-γ responses to phytohaemaglutinin and Staphylococcus aureus enterotoxin B (SEB) at the end of the supplementation period as well as eight weeks after ceasing supplementation. The increase in IFN-γ to SEB could be correlated with the decrease in the severity of AD. Editor's comment: Probiotics are harmless and may be helpful in young children with moderate to severe AD. Prescott SL, et al. Clin Exp Allergy 2005; 35:1557
4. PULMONARY FUNCTION TESTING AND THE MANAGEMENT OF ASTHMA IN CHILDREN
Children with asthma (n = 367, age 4 to 18 yrs) had spirometry before they were clinically evaluated by a nurse practitioner or pulmonologist. Spirometry was abnormal in 45% of the visits, related to underlying asthma severity but not to clinical findings. Such results changed management decisions in 15% of visits. The authors conclude that health care professionals often overestimate the degree of asthma control which can result in suboptimal therapy. Editor's comment: The National Asthma Educational Prevention Program Expert Report 2 recommends that spirometry be performed at the time of initial evaluation and that repeat spirometry be done after new therapy is initiated and peak expiratory flow (PEF) is stabilized to document normalization of airway function. Spirometry provides a more complete assessment of lung function than does PEF, especially of the small airways. Spirometry is also recommended at regular intervals to ensure maintenance of airway function. Nair SJ, et al. J Pediatr 2005; 147:797
5. MANAGEMENT OF ASTHMA BETTER UNDER THE CARE OF SPECIALIST
One thousand, two hundred fifty-six patients (mean age, 36.1 yrs, 54% female) were consecutively recruited in pharmacies to complete a questionnaire on their asthma management. Eleven point four percent, 36.6% and 52.0% were under the care of specialist (SPE), general practitioners (GP) and both GP and SPE, respectively. Fifty-two point two percent of those in the SPE group versus 26.4% and 21.5% in the GP and the SPE groups, respectively, were properly controlled. The SPE group used fixed combinations of long-acting beta-agonist and inhaled corticosteroids and the patient received less short-acting beta-agonist, antitussives and antibiotics. Editor's comment: Specialty care matters. Laforest L, et al. Eur. Respir J 2006; 27:42
6. THE GENOME SEQUENCE OF ASPERGILLUS FUMIGATUS
This paper reports the complete genetic sequence of the filamentous fungus Aspergillus fumigatus, which causes respiratory tract diseases and is allergenic. Several allergens have been previously described from this mold species. The complete sequencing has allowed identification of nine additional potential allergens or isoallergens, which heretofore have been unidentified. Although the genomic sequence analysis has revealed the entire list of allergens, the clinical significance of the new allergens remains to be established. Editor's comment: This is one fungal species for which all the allergens are identified. Nierman WC, et al. Nature 2005; 438:22
7. DERMATOPHAGOIDES AND BLOMIA SKIN TEST SENSITIZATION IN ALLERGIC PATIENTS IN VENEZUELA
The object of this study was to determine cutaneous sensitization rates to 3 mite extracts, Dermatophagoides pteronyssinus, Blomia kulagini, and Blomia tropicalis. Of 204 patients studied, almost all were sensitive to all three extracts, however, 9.3% were sensitive only to D. pteronyssinus and 2.4% only to B. tropicalis. None reacted exclusively to B. kulagini. The authors conclude that isolated sensitivity occurs to these different dust mite extracts. Editor's comment: Some patients can be exclusively sensitized to D. pteronyssinus or B. tropicalis. Capriles-Hulett A, et al. Allergy Clin Immunol Int – J World Allergy Org 2005; 17:224
8. SEAFOOD AND IODINE: AN ANALYSIS OF A MEDICAL MYTH
Seventy-five subjects in this study were confirmed to have shellfish or fish allergy. Of the 75, 92% (n = 69) believed that iodine in seafood was the cause of seafood allergy. Sixty-five percent (n = 49) of the patients either learned or were told that they should avoid radiocontrast media (RCM). Editor's comment: Many patients and physicians still believe the myth that iodine is responsible for shellfish and/or fish sensitivity and that RCM should be avoided. Huang S, Allergy and Asthma Proc 2005; 26:468
9. A REVIEW OF TOLL-LIKE RECEPTORS AND THEIR ROLE IN HOST DEFENSE AGAINST BACTERIAL INFECTIONS
This is an excellent review on toll-like receptors and their importance as principle mediators of rapid microbial recognition. These receptors function mainly by detection of structural patterns that do not exist in the host. In many instances, they insure a productive relationship between host and microbes. Editor's comment: The role of the innate immune system in health and disease continues to be investigated. Schnare M, et al. Int Arch Allergy Immunol 2006; 139:75
10. THE PATHOGENESIS OF OBSTRUCTIVE SLEEP APNEA (OSA)
Sleep apnea is a relatively new syndrome having been described in the medical literature over the past 100 years. The first article describes what is known about its pathogenesis and the second, the advances which have taken place in understanding and treating sleep-disordered breathing. Editor's comment: Both articles are excellent reviews about OSA which has been reported to be a risk factor for asthma exacerbation. White DP, Am J Respir Cell Mol Biol 2006; 34:1 and Pack AI, Am J Respir Crit Care Med 2006; 173:7. No abstract is available from Am J Respir Cell Mol Biol.
11. SAFETY OF LONG-ACTING BETA-AGONISTS
Long-acting beta-agonists (LABAs) may increase the chances of severe asthma and death. In this editorial, Dr. Martinez concludes that patients with mild to moderate asthma should be treated primarily with inhaled glucocorticoids (ICS) and supplemented with leukotriene-receptor antagonists and/or low-dose theophylline therapy. For more severe disease, he states that reevaluation of the patient should precede any additional therapeutic intervention because of non-compliance and coexisting problems which exacerbate asthma. Only then does he state that LABA's should be added to relieve symptoms. Editor's comment: LABA's and ICS have become one of the standards of care for moderate to severe asthma. More studies are necessary to better define the safety and possible risk-benefit of LABA's. Martinez FD, N Engl J Med 2005; 353:2637. No abstract is available for this article.
