Use Of Appropriate Therapy Research Articles

Dabigatran Versus Warfarin After Bioprosthesis Valve Replacement for the Management of Atrial Fibrillation Postoperatively: Protocol

BackgroundWarfarin and similar vitamin K antagonists have been the standard therapy for patients with mechanical or biological valve prosthesis and atrial fibrillation (AF). Even with the appropriate use of therapy, some studies have reported that there is a high incidence of thromboembolic events, 1%-4% per year. Furthermore, a bleeding risk is significant, ranging from 2% to 9% per year, according to some studies.ObjectiveThe objective of our study was to examine the effect of dabigatran etexilate versus dose-adjusted warfarin for the prevention of intracardiac thrombus in persistent or permanent AF at least 3 months after aortic and/or mitral bioprosthesis replacement.MethodsDabigatran versus warfarin after bioprosthesis valve replacement for the management of atrial fibrillation postoperatively (DAWA) is a phase 2, prospective, open label, randomized exploratory pilot study. The main variable to be observed in this study is intracardiac thrombus. From August 2013 to April 2015, 100 patients, at least 3 months after aortic and/or mitral bioprosthesis replacement and permanent or persistent AF postoperatively, who match eligibility criteria will be selected from Ana Nery Hospital in Salvador-Bahia with a follow-up of three months. Patients were randomly assigned in a 1:1 ratio to receive either dabigatran etexilate or warfarin.ResultsAlthough the present study has no statistic power to proof non-inferiority, it is expected that the dabigatran etexilate group will be protected as well as the warfarin group from intracardiac thrombus, without increasing the bleeding rates, since we are using safer doses (110 mg bid). The lack of necessity of monitoring INR is also another factor that contributes to a better adherence to the new drug and it can make all the difference in the manner of doing anticoagulation for patients with similar clinical characteristics.ConclusionsThe study is in the recruitment phase. It is possible that dabigatran etexilate is as effective as warfarin in preventing the emergence of intracardiac thrombus in patients with AF and mitral and/or aortic bioprosthesis.Trial RegistrationClinicaltrials.gov NCT01868243; http://clinicaltrials.gov/ct2/show/NCT01868243 (Archived by WebCite at http://www.webcitation/6OABiuasd).

TREATMENT OF ADULT PATIENTS WITH CRANIOCEREBRAL TRAUMA COMPLICATED BY VENITALORY FAILURE

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Piskorz J, Iłżecka J, Wójcik G. TREATMENT OF ADULT PATIENTS WITH CRANIOCEREBRAL TRAUMA COMPLICATED BY VENITALORY FAILURE. Health Problems of Civilization. 2014;8(2):4-9. doi:10.5114/hpc.2014.57071. APA Piskorz, J., Iłżecka, J., & Wójcik, G. (2014). TREATMENT OF ADULT PATIENTS WITH CRANIOCEREBRAL TRAUMA COMPLICATED BY VENITALORY FAILURE. Health Problems of Civilization, 8(2), 4-9. https://doi.org/10.5114/hpc.2014.57071 Chicago Piskorz, Jolanta, Joanna Iłżecka, and Gustaw Wójcik. 2014. "TREATMENT OF ADULT PATIENTS WITH CRANIOCEREBRAL TRAUMA COMPLICATED BY VENITALORY FAILURE". Health Problems of Civilization 8 (2): 4-9. doi:10.5114/hpc.2014.57071. Harvard Piskorz, J., Iłżecka, J., and Wójcik, G. (2014). TREATMENT OF ADULT PATIENTS WITH CRANIOCEREBRAL TRAUMA COMPLICATED BY VENITALORY FAILURE. Health Problems of Civilization, 8(2), pp.4-9. https://doi.org/10.5114/hpc.2014.57071 MLA Piskorz, Jolanta et al. "TREATMENT OF ADULT PATIENTS WITH CRANIOCEREBRAL TRAUMA COMPLICATED BY VENITALORY FAILURE." Health Problems of Civilization, vol. 8, no. 2, 2014, pp. 4-9. doi:10.5114/hpc.2014.57071. Vancouver Piskorz J, Iłżecka J, Wójcik G. TREATMENT OF ADULT PATIENTS WITH CRANIOCEREBRAL TRAUMA COMPLICATED BY VENITALORY FAILURE. Health Problems of Civilization. 2014;8(2):4-9. doi:10.5114/hpc.2014.57071.

Treatment goals for moderate to severe psoriasis: An Australian consensus

The high incidence of comorbidities in patients with psoriasis, significant impact on quality of life and patients' dissatisfaction with treatment led a European group to develop a consensus position on psoriasis treatment goals. There is an evident need for similar treatment goals in Australia. The aim of this project was to develop Australian treatment goals that reflect the local environment. A panel of 12 representatives was drawn from across Australia consisting of nine dermatologists and a rheumatologist, a dermatology nurse and a general practitioner (GP)/dermatology trainee. The group met on three occasions between September 2011 and March 2012. The panel undertook a literature review and critically examined available evidence-based treatment goals. A questionnaire relating to psoriasis assessment and specific treatment outcomes was developed. Following discussion and debate, recommended treatment goals for psoriasis patients in Australia were determined. The panel agreed by consensus on recommended psoriasis treatment goals in the Australian environment. There was recognition that in addition to psoriasis area severity index (PASI) assessment, a quality of life assessment was highly relevant in determining psoriasis severity and treatment outcome. Mild psoriasis was defined as PASI ≤ 10 and a dermatology life quality index (DLQI) ≤ 10, with moderate to severe psoriasis defined as PASI > 10 and/or DLQI > 10. The presence of certain definedclinical features would elevate a patient's classification from mild to moderate/severe. The target for treatment was defined as a maintained change in PASI ≥ 75% improvement and DLQI ≤ 5. These largely concurred with the European treatment goals. A flow chart for psoriasis management in Australia based on outcome measures was developed. There is a need to identify and articulate treatment goals for psoriasis. Assessment of psoriasis severity requires both physical scoring (PASI) and consideration of quality of life measures (DLQI). Identification of treatment goals will guide clinicians in treatment decision-making, enhance the availability and appropriate use of therapies and increase patient satisfaction with their care.

Intravenous antibiotics used in dermatology

It is not common for dermatologists to use intravenous antibiotics in daily practice. However, there are several serious infections that may come to the attention of a dermatologist because of cutaneous signs and symptoms. It is important for dermatologists to be familiar with the presenting symptoms, various stages of disease, and treatment for such infections, as good outcomes are achieved by early recognition and use of appropriate therapy. The following section reviews the treatment, with a focus on intravenous antimicrobial therapy, for several serious infections important to dermatologists: syphilis, Rocky Mountain spotted fever, Lyme disease, cellulitis, methicillin-resistant Staphylococcus aureus, Vibrio vulnificans, and necrotizing fasciitis.

P1 Clinical and economic benefit of cardiopulmonary exercise testing (CPX) in pulmonary hypertension

<h3>Rationale</h3> The exercise response in pulmonary hypertension (PH) has characteristic features, including decreased peak oxygen consumption, increased ventilatory inefficiency (VE/VCO2 slope) and widened alveolar-arterial gradient. These features can be used in diagnosing PH or distinguishing it from other causes of breathlessness. Many of the measurements from CPX are effort-independent, unlike the 6-min walk test, and can be used to discriminate uncontrolled PH from other factors which may affect peak capacity, such as obesity. We wished to evaluate the clinical and economic impact of CPX in PH. <h3>Methods</h3> We performed a retrospective analysis of 552 studies performed between August 2007 and August 2010. The impact of these tests was assessed by reviewing clinic letters and multidisciplinary team minutes. <h3>Results</h3> As a direct consequence of CPX, (1) 69 (13%) new non-PH diagnoses were made leading to changes in management and non-PH therapy in 18 (3%); (2) cardiac catheterisation was avoided in 69 (13%) and identified as necessary in 5 (1%), with a net saving of £179.5k; (3) 33 non-PH causes for patients9 symptoms were identified, preventing the addition of unnecessary and expensive therapies, saving £318.9k; 4) four patients were identified as needing additional therapy, albeit at greater cost (£26.6k); 5) finally, CPX facilitated confident discharge of patients in 38 (7%). The total saving using CPX over 3 years was £457.9k. Appropriate charging structures are not in place for CPX and testing was carried out using research facilities, however, a new national tariff for CPX is set at £235/test. This would still result in net saving of £328.2k (a <i>gain</i> of £594/test) in addition to the clinical benefit. We identified further savings of £93.6k which could have resulted from use of CPX earlier in the diagnostic process, increasing the net gain from £594 to £764 per test. <h3>Conclusion</h3> CPX provides clinical and financial benefit by directing investigations and treatments in a substantial number of cases. CPX prevented patients undergoing expensive and invasive investigations to establish diagnoses and monitor progression. CPX also improved appropriate use of therapies by characterising patients9 functional capacity and identifying when alternative conditions were responsible for patients9 deterioration.

Abstract P150: Modest Achievement of Guideline-Derived Treatment Goals in Diabetic Patients with Atherosclerotic Cardiovascular Disease Despite High Use of Guideline-Based Therapies

Background: Recent emphasis has been placed on enhancing quality of cardiovascular care using practice guidelines and health information technology to provide feedback to individual physicians. How effective this has been in achieving treatment goals versus percent of appropriate patients receiving guideline-based therapy is unclear. Accordingly, the purpose of this study was to determine how successfully guideline-derived treatment goals were met for outpatients with diabetes (DM) and ASCVD in an academic general cardiology practice with an electronic medical record (EMR). Methods: A retrospective study was conducted on all outpatients managed in an academic general cardiology clinic who had diagnoses of both ASCVD and DM and had ≥ 2 outpatient visits between January 2008 and September 2009 (n =926), during which time EMR quarterly “report cards” were provided. Values for LDL, HDL, BP and BMI were abstracted for the first and last visits during the study period. Analysis was conducted on the percent of patients achieving treatment goals at each visit and differences in values between first and last visit. Results: A high percentage of patients were receiving guideline-based drug therapy at their last visit: Statin - 91.0%; Anti-hypertensive, ACE or ARB - 83.4%; Anti-platelet - 92.0%; β-blocker - 75.7%. However, mean LDL at the last visit was 80.4±33.7, and although 81% (649/797) had an LDL-C &lt;= 100 mg/dl, only 41% (326/797) achieved an LDL-C &lt;= 70mg/dl. Similarly, only 61% (563/921) achieved a systolic BP &lt;= 130 mmHg, and mean reduction of BMI between the first and last visit was 1.3% (32.5±11.5 vs. 32.1±9.4, p=NS). The same number of patients gained 10% or more weight during the study period, as lost 10% or more weight, 5.3% (47/886). Conclusion: A very high percentage of patients were receiving guideline-based drugs, but with respect to achieving ATP III target LDL-C and systolic BP goals, there was less success. The greatest difficulty was in achieving weight loss. These results are similar to those achieved by randomized patients in the BARI-2D trial. In both studies, successful weight loss and achievement of LDL-C guidelines by ATP III were suboptimal although the use of appropriate therapy was high. Additional strategies are needed to achieve these targets.

Arrhythmic risk in congenital long QT syndrome

One of the most important and challenging aspects of caring for patients with congenital long QT syndrome (LQTS) is assessing an individual's risk of sudden cardiac death (SCD) because of torsades de pointes. Current risk assessment integrates clinical and genetic features known to be associated with SCD, but more accurate methods of risk assessment could lead to more appropriate use of therapies, potentially saving lives and avoiding overtreatment. Conventional indices of risk include sex, age, extent of QT prolongation, history of symptoms (syncope or aborted SCD), and genetic subtype. The biophysical properties of specific mutations (eg, those that affect transmembrane segments of the ion channel protein or those that cause a dominant negative effect on ion channel function vs haplotype insufficiency) also contribute to risk. A growing body of basic mechanistic and clinical evidence points to heterogeneity of repolarization as a potent determinant of risk in LQTS patients. Mechanistically, heterogeneities of repolarization provide substrate for reentry, which likely causes perpetuation of torsades de pointes. Clinical markers that reflect heterogeneity of repolarization include abnormal microvolt-level T wave alternans, increased Tpeak-end interval, and dispersion of mechanical contraction time. The optimal methodology for using these indices as risk predictors in LQTS remains under active investigation. Further studies are needed to determine how indices of heterogeneity such as microvolt-level T wave alternans, Tpeak-end interval, and dispersion of mechanical contraction can be incorporated into models of risk prediction in LQTS, both for initial risk stratification and for assessment of efficacy of therapies.

Appropriateness of therapy for fistulizing Crohn’s disease: findings from a national inflammatory bowel disease cohort

About 30-50% of patients with Crohn's disease (CD) develop fistulae, implying significant disease burden and complicated clinical management. To assess appropriate use of therapy for fistulizing CD patients enrolled in the Swiss Inflammatory Bowel Disease Cohort using criteria developed by the European Panel on the Appropriateness of Crohn's disease Therapy. Specific questionnaires were used to gather information on disease and its management. We assessed appropriateness of therapy at enrolment for adult CD patients with one or several fistulae. Two hundred and eighty-eight CD patients had fistulizing disease, of which 80% had complex fistulae and 32% currently had active draining fistulae. Mean age (s.d.) at diagnosis was 27 years (11), 51% males. Of the patients, 78% were judged as having globally an appropriate therapy, which was more often given for complex fistulae (87%) than for simple fistulae (67%). Antibiotics, azathioprine/MP, methotrexate and conservative surgery were almost always appropriate. Anti-tumor necrosis factor α was considered globally appropriate (91%), although most often with an uncertain indication. The 5ASA compounds, steroids and aggressive surgery were most often inappropriate (84%, 58% and 86% respectively). Formal appropriateness criteria for CD therapy were applied to a national cohort of IBD patients. For more than three-quarters of the patients with fistulizing CD, therapy was globally appropriate.

Dilated Cardiomyopathy With Conduction Disease and Arrhythmia

case presentation: A 48-year-old woman presents with exertional dyspnea and recurrent syncope. One year earlier, a permanent pacemaker was placed after she complained of fatigue and was found to have high-grade atrioventricular block. Now, she has echocardiographic evidence of moderate to severe left ventricular (LV) systolic dysfunction with regional wall-motion abnormalities. Nuclear imaging is notable for heterogeneous myocardial uptake of technetium Tc99m sestamibi, and coronary angiography reveals widely patent epicardial vessels. Multiple episodes of nonsustained ventricular tachycardia (VT) are documented on continuous ECG monitoring. What are the diagnostic considerations for this patient, and what further evaluations are indicated? This patient presents with dilated cardiomyopathy (DCM) with electric instability (DCM+E), which we define as conduction disease and arrhythmia out of proportion to the severity of LV systolic dysfunction. Diverse causes can result in DCM+E and fall into general categories of inflammatory, infectious, hereditary, and infiltrative processes. Cardiac presentation associated with these conditions is distinct from more common causes of DCM such as ischemic heart disease, viral myocarditis, valvular dysfunction, pregnancy, or substance abuse. Clinical features that are suggestive of DCM+E include supraventricular arrhythmias or conduction disease that precedes cardiomyopathy, multiple VT morphologies, and features suggestive of ischemic heart disease (Q waves, regional wall-motion abnormalities, perfusion defects, ventricular aneurysm) in the absence of epicardial stenoses. In this Clinician Update, we focus on the diagnostic approach to patients with DCM+E. Emphasis is placed on diagnoses that are relatively common or for which the clinical management would be impacted significantly by recognition of the underlying cause. Ischemic heart disease may present with conduction disease and a high burden of arrhythmia, especially in the setting of acute myocardial ischemia/infarction. The exclusion of obstructive coronary artery disease is strongly recommended in patients with DCM+E because atherosclerosis is so prevalent, evidence-based treatment is readily available, and the …

Imaging Findings of Primary Multidrug-Resistant Tuberculosis

This study was designed to identify and describe thin-section computed tomographic (CT) findings of primary multidrug-resistant tuberculosis (MDR TB) as compared with the findings for drug-sensitive TB. Between October 2002 and December 2007, thin-section chest CT findings of 39 patients with primary MDR TB and 39 patients with drug-sensitive TB were retrospectively reviewed. The frequency and patterns of lung lesions (including centrilobular nodules, large nodules, consolidation, cavity, fibrotic bands, bronchiectasis, calcification, pleural effusion, lymphadenopathy, number of lobes affected by parenchymal lesions, and laterality) were compared. Statistical comparisons were performed with the use of the chi2 and the Mann-Whitney U tests for univariate analysis, and a stepwise logistic regression method was used for multivariate analysis. Based on univariate analysis, bilateral involvement (P < 0.001), segmental or lobar consolidation (P < 0.001), and cavities (P < 0.001) were more frequently seen in primary MDR TB patients. A stepwise logistic regression analysis demonstrated that bilateral involvement of parenchymal lesions (odds ratio, 4.7; 95% confidence interval, 1.4-15.6; P = 0.012) and multiple cavities (odds ratio, 1.7; 95% confidence interval, 1.2-2.5; P = 0.004) were significant CT findings associated with primary MDR TB. The presence of primary MDR TB as detected on a CT scan may help the use of appropriate therapy for infected patients before obtaining a definite diagnosis based on bacteriology.

A Systematic Review of Barriers and Interventions to Improve Appropriate Use of Therapies for Sickle Cell Disease

Clinical experts have expressed concern about underutilization of sickle cell disease (SCD) therapies, including hydroxyurea, prophylactic antibiotics, iron chelation, bone marrow transplantation, pain management during vaso-occlusive crisis, and receipt of routine ambulatory health care. We synthesized studies that identified barriers to and interventions to improve appropriate use of these therapies. Of the 48 studies included in our review, 35 identified therapeutic barriers or facilitators, and 13 evaluated interventions to improve use of therapies. Consistently identified barriers to appropriate pain management were negative provider attitudes and lack of provider knowledge. Four of 9 pain management interventions improved direct measures of pain management quality, while 5 improved indirect measures. One intervention improved receipt of routine ambulatory care. We concluded that interventions to improve pain management in SCD can be effective and should address providers' negative attitudes and knowledge and that more intervention studies are needed to improve receipt of recommended SCD therapies.

Hereditary Hemochromatosis: Time for Targeted Screening

The discovery of the HFE gene in 1996 heralded a decade of major advances in the understanding of the mechanisms that control iron absorption and body iron stores. A genetic definition of the common form of hereditary hemochromatosis became possible, and testing for the common causative HFE mutations is now widely available in clinical laboratories. Several population screening studies have confirmed that disease penetrance in HFE-related hereditary hemochromatosis is lower than previously believed, making universal population-based screening for this disorder unattractive. However, hereditary hemochromatosis may still cause morbidity and mortality because of iron overload. Early detection and use of appropriate therapy can prevent these manifestations and can only be achieved by targeted case finding. In this article, the authors draw attention again to hereditary hemochromatosis as a cause of preventable organ dysfunction and propose targeted case finding for Caucasian men of Northern European ancestry.

Profile of drug utilization in the elderly living in Porto Alegre, Brazil.

The elderly population is one of the most rapidly increasing populations in the world. Physiological alterations induced by the aging process make these individuals more susceptible to chronic diseases and, consequently, to increased drug utilization. To describe the profile of drug utilization in the elderly living in Porto Alegre, RS, Brazil. An observational and cross-sectional population-based study to investigate the characteristics of the population, sources of information and types of drugs used by the elderly was performed. Four hundred and eighty patients were recruited from data supplied by the City Hall of Porto Alegre. The elderly were interviewed individually during the period from January to May 2006 by trained interviewers. A validated pharmacotherapy questionnaire was used for data collection and data were tabulated and analyzed by the SPSS 11.5 computer program. Of the 480 patients interviewed, 13.8% did not use any medication. Cardiovascular system drugs represented the pharmacological class most used by the elderly (64.0%). When ill, 71.9% of these individuals visited the doctor, while 36.9% self-medicated. For the majority (50.2%), drugs were identified by their labels. Only 41.2% of the elderly understood medical prescriptions and 68.3% of the patients studied obtained the necessary information for the appropriate use of therapy from their doctors. The present study suggests that a pharmaceutical care program for the treatment, prevention, and use of medications may provide a higher efficiency to elderly drug therapy.

The influence of metallo- -lactamase production on mortality in nosocomial Pseudomonas aeruginosa infections

To assess the effect of metallo-beta-lactamase (MBL) production on Pseudomonas aeruginosa nosocomial infection mortality and to identify the determinants of such effect. A cohort study of patients with P. aeruginosa nosocomial infections was conducted at two teaching hospitals. MBL was detected by ceftazidime/2-mercaptopropionic disc approximation test and selected isolates were submitted to PCR using bla(SPM-1) primer. Molecular typing was performed by DNA macrorestriction. To evaluate the influence of MBL on mortality a Cox proportional hazards model was performed using a hierarchized framework of the variables. A total of 298 patients with P. aeruginosa infections were included. Infections by MBL-carrying Pseudomonas aeruginosa (MBL-PA) resulted in higher in-hospital mortality than those by non-MBL-PA (51.2% versus 32.1%, respectively; relative risk 1.60, 95% CI 1.20-2.12) and higher mortality rates [17.3 per 1000 versus 11.8 per 1000 patient-days, respectively; hazard ratio (HR) 1.55, 95% CI 1.06-2.27]. In the final multivariate model, severe sepsis or septic shock [adjusted HR (AHR) 3.62, 95% CI 2.41-5.43], age (AHR 1.02, 95% CI 1.01-1.03) and use of appropriate therapy<or=72 h (AHR 0.49, 95% CI 0.32-0.76) were significantly associated with mortality. Fourteen MBL-PA tested carried the blaSPM-1 gene. Clonal dissemination was documented in both hospitals. MBL-PA infections resulted in higher mortality rates most likely related to the severity of these infections and less frequent early institution of appropriate antimicrobial therapy. Empirical treatments should be reviewed at institutions with high prevalence of MBL.

Clinical factors associated with fluconazole resistance and short-term survival in patients with Candida bloodstream infection.

In a 1-year national surveillance program of Candida bloodstream infections in Japan, clinical factors predicting fluconazole resistance and survival of the patients were analyzed. Blood isolates and complete clinical histories were obtained from 326 patients. Fluconazole-resistant isolates were found in 15 (4.6%) of the cases. Univariate analysis of the demographic and clinical factors associated with fluconazole resistance revealed that age, hematologic malignancy, neutropenia, and immunosuppression were of statistical significance. A multiple logistic regression model showed that only hematologic malignancy as the underlying disease (odds ratio, 6.6; 95% confidence interval, 1.6-26.9; P=0.009) was independently associated with resistance. In 242 cases in which data regarding management and prognosis were available, the 30-day survival rate was 68.4%. In the univariate analysis of factors predicting survival, a significant association was found for Candida species, age of the patient, neutropenia, recent abdominal surgery, removal of the central venous catheter, and use of appropriate antifungal therapy. In the multivariate analysis, removal of the central venous catheter (odds ratio, 6.0; 95% confidence interval, 2.2-16.1; P<0.001) and the use of appropriate therapy (odds ratio, 2.1; 95% confidence interval, 1.1-4.1; P=0.03) were independent factors significantly associated with survival after the diagnosis of Candida bloodstream infection.

AACN Synergy Model for Patient Care

within the walls of the hospital setting. Today’s healthcare environment mandates that patients with serious diseases live in their homes, causing the need for acute and critical care settings to reach out to their patients not only to assist them in maintaining a quality of life but also to decrease costs of hospital readmissions. This situation is especially true for patients with chronic heart failure (CHF). In the United States, many patients with CHF regularly visit CHF clinics that are run by advanced practice nurses; these clinics assist patients with maintaining and often improving their state of heart failure, while also proving cost-effective. The Synergy Model provides the framework for nurses to manage complex clients experiencing acute exasperation of their illness and to work toward reducing the trajectory of the illness. The purpose of this article is to discuss the application of The Synergy Model to an ambulatory CHF clinic. We will discuss the characteristics of a patient who visited a local clinic, with the advanced practice nurse holding a Authors

The International Sepsis Forum's controversies in sepsis: how will sepsis be treated in 2051?

Great advances have been made in describing the intracellular pathways and genes that are activated by bacterial products. New definitions and therapies for sepsis will be based on such cellular and genetic alterations. In particular, in 2051 sepsis will no longer be defined simply as a clinical constellation of findings, but rather will be divided into different entities dependent on the intracellular cascades or genes activated. Similarly, therapies will be specifically directed at such functional genetic or biochemical alterations, thereby permitting more rational therapy of specific cellular abnormalities in infected patients. Supportive care will also have advanced by 2051, allowing for less iatrogenic harm to critically ill septic patients. Finally, a better appreciation of the cellular and genetic pathways that are activated in patients will permit an improved understanding of prognosis in critically ill infected patients, allowing more appropriate use of therapies.

CORTICOSTEROIDS IN THE TREATMENT OF ALLERGIC RHINITIS

Allergic rhinitis is the most common of the allergic disorders, affecting at least 10% and perhaps more than 20% of the United States population. 27,65 It can affect individuals of all ages, beginning even in infancy. Although immunoglobulin E (IgE) production tends to decrease in older persons, allergic rhinitis does affect this age group also, and very occasionally may begin in elderly individuals. Allergic rhinitis is most prevalent in children and adolescents, however, and onset occurs before the age of 30 years in most patients. 72 Allergic rhinitis is the most common chronic illness in persons 30 years of age and younger and is the fifth most common chronic illness in the overall population. 74 Allergic rhinitis manifests as a perennial, seasonal, or episodic disorder, often with significant variation of symptoms and severity from day to day. Seasonally increased difficulties may overlap chronic perennial symptoms. The symptoms may vary in severity from trivial to disabling. Although nasal symptoms may predominate, other non-nasal and systemic symptoms may contribute to substantial dysfunction, resulting in lost school and work days, 65,92 interference with normal day-to-day functioning, loss of intellectual 8,90 and physical productivity, and general diminution of quality of life. 4 Allergic rhinitis is not life-threatening, but it does threaten the quality of life. Recently appreciated, also, is its association and possibly pathogenic relationship with chronic sinusitis, otitis media with effusion, and bronchial asthma. 4,93,95 The costs for allergic rhinitis are high. The total cost of allergic rhinitis was estimated to be $1.8 billion in 1990 61 and $2.4 billion in 1995. 82 These figures do not include the costs of associated disorders. Approximately 50% of persons with symptoms do not go to a physician for treatment, however. (One important reason seems to be concern about the side effects of prescribed agents.) 49 Tolerance for symptoms varies considerably among patients, with many patients choosing simply to endure the symptoms despite suboptimal functioning. Thus, true costs for all patients with allergic rhinitis are probably far in excess of the estimates given. Allergic rhinitis is associated with several other conditions, some of which are probably caused by the mechanical obstruction associated with nasal tissue inflammation (e.g., otitis media with effusion caused by eustachian tube dysfunction, and chronic sinusitis). 4 In children, facial bone abnormalities can develop as a result of chronic mouth breathing from allergic rhinitis with nasal obstruction. Nocturnal nasal obstruction can cause snoring, obstructive sleep apnea, poor sleep patterns, and daytime somnolence. 21,84 Nasal polyps may develop, especially in adults, although polyps are equally likely to occur in patients without an allergic basis for their rhinitis. Hyposmia or anosmia with associated diminished sense of taste may occur with allergic rhinitis and can be associated with a decreased appetite. There may be complaints of abdominal discomfort, especially if postnasal drainage is a significant symptom, and especially in children. Patients with allergic rhinitis may be more susceptible to viral upper respiratory tract infections. 4,6 Allergic conjunctivitis frequently occurs in patients with nasal allergies, and asthma is a common comorbid condition with allergic rhinitis. Asthma may be found in up to 15% of persons with allergic rhinitis, 91 and most patients with asthma have allergic rhinitis. 4,88,95 A substantial number of patients with allergic rhinitis have exercise-induced bronchospasm. 93 Further, as a group, patients with allergic rhinitis without asthma symptoms tend to have increased bronchial responsiveness, 93 to exhibit an increase in diurnal variation of peak flows, 78 and appear to have an increased risk of developing asthma. 88 Thus, allergic rhinitis further contributes to increased morbidity and to the costs associated with various other disorders. Symptoms of allergic rhinitis, including nasal congestion, sneezing, rhinorrhea, and nasal itching can occur singly or in various combinations; associated symptoms may include postnasal drainage and itching of the eyes and of other non-nasal areas such as the palate, throat, face, neck, scalp, and external auditory canals. Systemic symptoms can include headache, torpor, malaise, somnolence, fatigue, decreased energy, inability to concentrate, and irritability. Feelings of embarrassment and frustration over symptoms may occur. 4,8 Emotional and learning problems in children have been noted. 8,90 Central nervous system effects may be subtle but still interfere with intellectual functioning at school or work. These CNS effects can be ameliorated or eliminated with the use of appropriate therapy, 103,104 but some types of treatment, such as first-generation antihistamines with their frequent attendant sedative effects, may intensify these problems. 82

Management of the oral mucosal lesions seen in association with HIV infection.

Oral lesions cause considerable morbidity in association with HIV infection. Their successful management depends upon accurate diagnosis and the use of appropriate therapy. Various treatment approaches are described for some of the common oral lesions including Kaposi's sarcoma, oral candidiasis, hairy leukoplakia and recurrent oral ulcers associated with HIV disease. This paper will discuss the therapies available in the USA and UK. In other countries some of the drugs discussed will be available in different doses and preparations. In addition other drugs may be available in other parts of the world that are not licensed for use in the USA or UK, and their availability may vary.

Update on Tuberculosis Skin Testing of Children

In January 1994, the Committee on Infectious Diseases published detailed guidelines on tuberculin skin testing of infants, children, and adolescents for the detection of tuberculous infections. This supplement to the 1994 statement is written to update and clarify several issues regarding the frequency of skin testing for children at increased risk of acquiring tuberculosis. In this document, children will refer to infants, children, and adolescents. The recommendations regarding the preferred use of the Mantoux skin test and the interpretation of skin test results remain unchanged and will not be repeated here. The interpretation guidelines for indurations of 5, 10, and 15 mm in diameter basically remain unchanged (Table 1). The overall emphasis to control tuberculosis in the United States should be placed on access to health care, a thorough history taking of exposure to infectious persons, timely and effective contact investigations, proper interpretation of Mantoux skin tests, and appropriate use of therapy, including directly observed therapy. Variations in the epidemiology of tuberculosis in different locations reinforce the importance of communication with local public health officials and/or experts on tuberculosis. Existing publications can assist in assessing the local risk of acquiring tuberculosis. The recommendations should be considered regardless of previous BCG vaccine administration. The American Academy of Pediatrics continues to encourage focusing tuberculin skin testing on children who are at increased risk of acquiring tuberculosis. Routine tuberculin testing, including school-based programs that include populations at low risk, has either a low yield of positive results or a large number of false-positive results and represents an inefficient use of limited health care resources.