Kerri Wachter

WASHINGTON — Pneumonia, sinus infections, and antibiotic use in a child's first year of life were independently associated with asthma in a study of more than 1,000 children with food allergies.

Children with a history of antibiotic use in the first year of life had an almost twofold increased risk of asthma (odds ratio, 1.8), after adjustment for age, sex, household income, maternal education, breastfeeding, mode of delivery, family atopy, and intrafamilial correlations. Even after adjustment for antibiotic use, pneumonia and sinus infection in early life were significantly associated with an increased risk of asthma (OR, 2.2 and 2.0), Angela Schroeder and her coinvestigators reported in a poster presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The study involved 1,105 children enrolled in an ongoing family-based food-allergy study in Chicago. The researchers used a questionnaire-based interview to obtain information about food allergies and medical histories of each family member.

A clinical evaluation—including measures of height, weight, and blood pressure and a skin prick test—was performed on each participating family member. Venous blood samples also were taken. In addition, ICD-9 codes were collected for children who received care in the allergy and immunology clinic at Children's Memorial Hospital, Chicago; those were compared with parental report of physician diagnosis in the child's first year.

The investigators determined antibiotic use in early life by questionnaire-based interviews and defined it by parental report of physician-prescribed antibiotics in their child's first year of life. They also assessed early infections by questionnaire-based interviews for otitis media, pneumonia, skin infection, urinary tract infection, parasite infection, bone infection, meningitis, bacteremia/sepsis, and sinus infection. The researchers defined asthma as parental report of physician diagnosis and being symptomatic in the year prior to the survey, as determined by interview. They determined the earliest age of reported asthma symptoms.

In all, 30% of children had asthma. Half of children with asthma had otitis media in the first year of life, compared with 40% of children without asthma. Likewise, 7% of children with asthma had pneumonia and 9% had sinus infection, compared with 2% and 4% of children without asthma.

More than two-thirds of children with asthma (68%) had used antibiotics in the first year of life, compared with 54% of children without asthma.

All of the differences were statistically significant.

Ms. Schroeder, who is a research associate at Children's Memorial Hospital, reported that she has no relevant financial relationships.

WASHINGTON — Pneumonia, sinus infections, and antibiotic use in a child's first year of life were independently associated with asthma in a study of more than 1,000 children with food allergies.

Children with a history of antibiotic use in the first year of life had an almost twofold increased risk of asthma (odds ratio, 1.8), after adjustment for age, sex, household income, maternal education, breastfeeding, mode of delivery, family atopy, and intrafamilial correlations. Even after adjustment for antibiotic use, pneumonia and sinus infection in early life were significantly associated with an increased risk of asthma (OR, 2.2 and 2.0), Angela Schroeder and her coinvestigators reported in a poster presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The study involved 1,105 children enrolled in an ongoing family-based food-allergy study in Chicago. The researchers used a questionnaire-based interview to obtain information about food allergies and medical histories of each family member.

A clinical evaluation—including measures of height, weight, and blood pressure and a skin prick test—was performed on each participating family member. Venous blood samples also were taken. In addition, ICD-9 codes were collected for children who received care in the allergy and immunology clinic at Children's Memorial Hospital, Chicago; those were compared with parental report of physician diagnosis in the child's first year.

The investigators determined antibiotic use in early life by questionnaire-based interviews and defined it by parental report of physician-prescribed antibiotics in their child's first year of life. They also assessed early infections by questionnaire-based interviews for otitis media, pneumonia, skin infection, urinary tract infection, parasite infection, bone infection, meningitis, bacteremia/sepsis, and sinus infection. The researchers defined asthma as parental report of physician diagnosis and being symptomatic in the year prior to the survey, as determined by interview. They determined the earliest age of reported asthma symptoms.

In all, 30% of children had asthma. Half of children with asthma had otitis media in the first year of life, compared with 40% of children without asthma. Likewise, 7% of children with asthma had pneumonia and 9% had sinus infection, compared with 2% and 4% of children without asthma.

More than two-thirds of children with asthma (68%) had used antibiotics in the first year of life, compared with 54% of children without asthma.

All of the differences were statistically significant.

Ms. Schroeder, who is a research associate at Children's Memorial Hospital, reported that she has no relevant financial relationships.

WASHINGTON — Pneumonia, sinus infections, and antibiotic use in a child's first year of life were independently associated with asthma in a study of more than 1,000 children with food allergies.

Children with a history of antibiotic use in the first year of life had an almost twofold increased risk of asthma (odds ratio, 1.8), after adjustment for age, sex, household income, maternal education, breastfeeding, mode of delivery, family atopy, and intrafamilial correlations. Even after adjustment for antibiotic use, pneumonia and sinus infection in early life were significantly associated with an increased risk of asthma (OR, 2.2 and 2.0), Angela Schroeder and her coinvestigators reported in a poster presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The study involved 1,105 children enrolled in an ongoing family-based food-allergy study in Chicago. The researchers used a questionnaire-based interview to obtain information about food allergies and medical histories of each family member.

A clinical evaluation—including measures of height, weight, and blood pressure and a skin prick test—was performed on each participating family member. Venous blood samples also were taken. In addition, ICD-9 codes were collected for children who received care in the allergy and immunology clinic at Children's Memorial Hospital, Chicago; those were compared with parental report of physician diagnosis in the child's first year.

The investigators determined antibiotic use in early life by questionnaire-based interviews and defined it by parental report of physician-prescribed antibiotics in their child's first year of life. They also assessed early infections by questionnaire-based interviews for otitis media, pneumonia, skin infection, urinary tract infection, parasite infection, bone infection, meningitis, bacteremia/sepsis, and sinus infection. The researchers defined asthma as parental report of physician diagnosis and being symptomatic in the year prior to the survey, as determined by interview. They determined the earliest age of reported asthma symptoms.

In all, 30% of children had asthma. Half of children with asthma had otitis media in the first year of life, compared with 40% of children without asthma. Likewise, 7% of children with asthma had pneumonia and 9% had sinus infection, compared with 2% and 4% of children without asthma.

More than two-thirds of children with asthma (68%) had used antibiotics in the first year of life, compared with 54% of children without asthma.

All of the differences were statistically significant.

Ms. Schroeder, who is a research associate at Children's Memorial Hospital, reported that she has no relevant financial relationships.

BALTIMORE — Propranolol for the treatment of severe infantile hemangiomas is getting some buzz in pediatric dermatology circles, and results from a new patient series support the interest.

Investigators at Johns Hopkins University treated 25 patients for a total 35 hemangiomas with propranolol. Dr. Katherine B. Puttgen reported interim results for 20 children—with a mean therapy duration of 3.7 months—at the Atlantic Dermatologic Conference. In all, 14 children (70%) who completed treatment had moderate or marked hemangioma improvement.

Interest in using the beta-blocker for the treatment of hemangiomas was piqued by a letter in the New England Journal of Medicine, in which French researchers reported that severe hemangiomas on 11 infants dramatically improved with propranolol (N. Engl. J. Med. 2008;358:2649–51). The letter “created a firestorm of activity and enthusiasm in the pediatric dermatology community,” said Dr. Puttgen, who is an assistant professor of pediatric dermatology at the Johns Hopkins University.

The mechanism of action for propranolol is unknown though “clearly there must be something vasoconstrictive going on in the hemangioma because within a couple of days of the initiation of therapy, the hemangiomas tend to become much softer … and more violaceous in color,” Dr. Puttgen said.

At Hopkins, pediatric cardiologists suggested admitting the infants for monitoring for 2–3 days because of the rapid dose escalation. The infants are started at a dose of 1 mg/kg per day, which is doubled 24 hours later. All of the infants get a baseline EKG. While the children are in the hospital, vital signs and blood glucose levels are measured 1 hour after each dose. Serial photographs are taken to measure change over time. After the infants are discharged, their blood pressure and heart rate should be checked at their pediatrician's office every 48 hours for the first week.

In the series, girls out-numbered boys 4:1. Most of the infants were white (20), 2 were black, 2 were Hispanic, and 1 was of Middle Eastern descent. Patients ranged in age from 28 days to 5 years, though most of the children were started on treatment at 2–4 months of age (mean 239 days, median 97 days).

Most of the patients (84%) had facial hemangiomas, most of which were focal (88%); 56% were of a mixed morphologic subtype. The most common complication was ulceration (32%). The biggest concern with propranolol is the risk for hypotension and low blood glucose in patients. One patient discontinued treatment due to hypotension.

None of the hemangiomas have worsened, Dr. Puttgen noted. Five patients had no or minimal change, two of whom were older. Three patients were considered to have moderate improvement, and 11 had marked improvement. Five infants were excluded because they are still on the treatment.

While many infants have impressive results, it is already clear that not all hemangiomas respond to propranolol, Dr. Puttgen noted.

Dr. Anthony J. Mancini, of Children's Memorial Hospital in Chicago, cautioned that the results are impressive but a number of questions need to be answered before propranolol becomes widely used for infantile hemangiomas.

Dr. Puttgen reported having no relevant financial conflicts of interest.

Despite 3 weeks of prednisolone, this infant's hemangioma remained severe on day 1 of propranolol therapy (left). Follow-up is shown 7 months later (right). Photos courtesy Dr. Katherine B. Puttgen

BALTIMORE — Propranolol for the treatment of severe infantile hemangiomas is getting some buzz in pediatric dermatology circles, and results from a new patient series support the interest.

Investigators at Johns Hopkins University treated 25 patients for a total 35 hemangiomas with propranolol. Dr. Katherine B. Puttgen reported interim results for 20 children—with a mean therapy duration of 3.7 months—at the Atlantic Dermatologic Conference. In all, 14 children (70%) who completed treatment had moderate or marked hemangioma improvement.

Interest in using the beta-blocker for the treatment of hemangiomas was piqued by a letter in the New England Journal of Medicine, in which French researchers reported that severe hemangiomas on 11 infants dramatically improved with propranolol (N. Engl. J. Med. 2008;358:2649–51). The letter “created a firestorm of activity and enthusiasm in the pediatric dermatology community,” said Dr. Puttgen, who is an assistant professor of pediatric dermatology at the Johns Hopkins University.

The mechanism of action for propranolol is unknown though “clearly there must be something vasoconstrictive going on in the hemangioma because within a couple of days of the initiation of therapy, the hemangiomas tend to become much softer … and more violaceous in color,” Dr. Puttgen said.

At Hopkins, pediatric cardiologists suggested admitting the infants for monitoring for 2–3 days because of the rapid dose escalation. The infants are started at a dose of 1 mg/kg per day, which is doubled 24 hours later. All of the infants get a baseline EKG. While the children are in the hospital, vital signs and blood glucose levels are measured 1 hour after each dose. Serial photographs are taken to measure change over time. After the infants are discharged, their blood pressure and heart rate should be checked at their pediatrician's office every 48 hours for the first week.

In the series, girls out-numbered boys 4:1. Most of the infants were white (20), 2 were black, 2 were Hispanic, and 1 was of Middle Eastern descent. Patients ranged in age from 28 days to 5 years, though most of the children were started on treatment at 2–4 months of age (mean 239 days, median 97 days).

Most of the patients (84%) had facial hemangiomas, most of which were focal (88%); 56% were of a mixed morphologic subtype. The most common complication was ulceration (32%). The biggest concern with propranolol is the risk for hypotension and low blood glucose in patients. One patient discontinued treatment due to hypotension.

None of the hemangiomas have worsened, Dr. Puttgen noted. Five patients had no or minimal change, two of whom were older. Three patients were considered to have moderate improvement, and 11 had marked improvement. Five infants were excluded because they are still on the treatment.

While many infants have impressive results, it is already clear that not all hemangiomas respond to propranolol, Dr. Puttgen noted.

Dr. Anthony J. Mancini, of Children's Memorial Hospital in Chicago, cautioned that the results are impressive but a number of questions need to be answered before propranolol becomes widely used for infantile hemangiomas.

Dr. Puttgen reported having no relevant financial conflicts of interest.

Despite 3 weeks of prednisolone, this infant's hemangioma remained severe on day 1 of propranolol therapy (left). Follow-up is shown 7 months later (right). Photos courtesy Dr. Katherine B. Puttgen

BALTIMORE — Propranolol for the treatment of severe infantile hemangiomas is getting some buzz in pediatric dermatology circles, and results from a new patient series support the interest.

Investigators at Johns Hopkins University treated 25 patients for a total 35 hemangiomas with propranolol. Dr. Katherine B. Puttgen reported interim results for 20 children—with a mean therapy duration of 3.7 months—at the Atlantic Dermatologic Conference. In all, 14 children (70%) who completed treatment had moderate or marked hemangioma improvement.

Interest in using the beta-blocker for the treatment of hemangiomas was piqued by a letter in the New England Journal of Medicine, in which French researchers reported that severe hemangiomas on 11 infants dramatically improved with propranolol (N. Engl. J. Med. 2008;358:2649–51). The letter “created a firestorm of activity and enthusiasm in the pediatric dermatology community,” said Dr. Puttgen, who is an assistant professor of pediatric dermatology at the Johns Hopkins University.

The mechanism of action for propranolol is unknown though “clearly there must be something vasoconstrictive going on in the hemangioma because within a couple of days of the initiation of therapy, the hemangiomas tend to become much softer … and more violaceous in color,” Dr. Puttgen said.

At Hopkins, pediatric cardiologists suggested admitting the infants for monitoring for 2–3 days because of the rapid dose escalation. The infants are started at a dose of 1 mg/kg per day, which is doubled 24 hours later. All of the infants get a baseline EKG. While the children are in the hospital, vital signs and blood glucose levels are measured 1 hour after each dose. Serial photographs are taken to measure change over time. After the infants are discharged, their blood pressure and heart rate should be checked at their pediatrician's office every 48 hours for the first week.

In the series, girls out-numbered boys 4:1. Most of the infants were white (20), 2 were black, 2 were Hispanic, and 1 was of Middle Eastern descent. Patients ranged in age from 28 days to 5 years, though most of the children were started on treatment at 2–4 months of age (mean 239 days, median 97 days).

Most of the patients (84%) had facial hemangiomas, most of which were focal (88%); 56% were of a mixed morphologic subtype. The most common complication was ulceration (32%). The biggest concern with propranolol is the risk for hypotension and low blood glucose in patients. One patient discontinued treatment due to hypotension.

None of the hemangiomas have worsened, Dr. Puttgen noted. Five patients had no or minimal change, two of whom were older. Three patients were considered to have moderate improvement, and 11 had marked improvement. Five infants were excluded because they are still on the treatment.

While many infants have impressive results, it is already clear that not all hemangiomas respond to propranolol, Dr. Puttgen noted.

Dr. Anthony J. Mancini, of Children's Memorial Hospital in Chicago, cautioned that the results are impressive but a number of questions need to be answered before propranolol becomes widely used for infantile hemangiomas.

Dr. Puttgen reported having no relevant financial conflicts of interest.

Despite 3 weeks of prednisolone, this infant's hemangioma remained severe on day 1 of propranolol therapy (left). Follow-up is shown 7 months later (right). Photos courtesy Dr. Katherine B. Puttgen

BALTIMORE — There's a growing appreciation among pediatric psychiatrists that mental illnesses occur among preschoolers and that identification and treatment are critical to getting these kids back on track for healthy development, according to Dr. Joyce N. Harrison, director of Preschool Clinical Programs at Johns Hopkins Bayview Medical Center in Baltimore.

“When I was in training 15 years ago, I thought all psychiatric disorders started at age 6 because that's when we started seeing kids, but we've begun to see kids younger and younger,” she said at a meeting on developmental disabilities sponsored by Johns Hopkins University.

Around 10% of preschoolers are believed to have a severe impairing psychiatric disorder; rates of attention-deficit/hyperactivity disorder, disruptive behavior disorders, depression, and anxiety in preschool children are estimated at 3%, 8%, 2%, and 9%, respectively.

Symptoms of these disorders can interfere with parent-child relationships, family functioning, social development, the ability to participate in child care, and with learning and school readiness.

“We have a very narrow window to get them back on the developmental trajectory,” she said. During early childhood, brain development is rapid and attachment to caregivers is critical. All learning occurs within the context of relationships and life experiences have a profound effect on later development.

Nationally, early care and education providers report that challenging behavior and problems with social skills are their greatest challenge; preschoolers are expelled at a rate three times higher than that for school-aged children, according to Dr. Harrison.

In 2006–2007, 67% of the referrals to the Michigan Child Care Expulsion Prevention Initiative were for children aged 0–3 years. That state-funded project is aimed at supporting the mental health needs of children ages 0–5 years. Children are referred to the program for frequent aggressive behavior such as biting, or for developmental concerns.

An estimated 10%–15% of children aged 1–2 years have significant social-emotional problems, according to Dr. Harrison. “The prevalence of social/emotional behavior problems in preschoolers is almost at epidemic proportions,” Dr. Harrison said.

“A stereotypical presentation in my clinic is a kid who is aggressive and they don't sleep and they're out of control or they're hyperactive,” Dr. Harrison said. “My approach is that it's a disruptive behavior disorder until proven otherwise, until we can get at what's underneath the behavior,” she said.

The evaluation process usually requires three to five sessions, and family interviews are the preferred method for obtaining information. Such interviews elicit details about the reason for the referral, current difficulties, traumatic events; temperament; family, medical and developmental history; and physical, cognitive, emotional, and social development. Child/caregiver interactions warrant observation, as does the child when playing alone and with other children. Standardized instruments are used for these evaluations.

Dr. Harrison reported that she has no relevant financial relationships.

BALTIMORE — There's a growing appreciation among pediatric psychiatrists that mental illnesses occur among preschoolers and that identification and treatment are critical to getting these kids back on track for healthy development, according to Dr. Joyce N. Harrison, director of Preschool Clinical Programs at Johns Hopkins Bayview Medical Center in Baltimore.

“When I was in training 15 years ago, I thought all psychiatric disorders started at age 6 because that's when we started seeing kids, but we've begun to see kids younger and younger,” she said at a meeting on developmental disabilities sponsored by Johns Hopkins University.

Around 10% of preschoolers are believed to have a severe impairing psychiatric disorder; rates of attention-deficit/hyperactivity disorder, disruptive behavior disorders, depression, and anxiety in preschool children are estimated at 3%, 8%, 2%, and 9%, respectively.

Symptoms of these disorders can interfere with parent-child relationships, family functioning, social development, the ability to participate in child care, and with learning and school readiness.

“We have a very narrow window to get them back on the developmental trajectory,” she said. During early childhood, brain development is rapid and attachment to caregivers is critical. All learning occurs within the context of relationships and life experiences have a profound effect on later development.

Nationally, early care and education providers report that challenging behavior and problems with social skills are their greatest challenge; preschoolers are expelled at a rate three times higher than that for school-aged children, according to Dr. Harrison.

In 2006–2007, 67% of the referrals to the Michigan Child Care Expulsion Prevention Initiative were for children aged 0–3 years. That state-funded project is aimed at supporting the mental health needs of children ages 0–5 years. Children are referred to the program for frequent aggressive behavior such as biting, or for developmental concerns.

An estimated 10%–15% of children aged 1–2 years have significant social-emotional problems, according to Dr. Harrison. “The prevalence of social/emotional behavior problems in preschoolers is almost at epidemic proportions,” Dr. Harrison said.

“A stereotypical presentation in my clinic is a kid who is aggressive and they don't sleep and they're out of control or they're hyperactive,” Dr. Harrison said. “My approach is that it's a disruptive behavior disorder until proven otherwise, until we can get at what's underneath the behavior,” she said.

The evaluation process usually requires three to five sessions, and family interviews are the preferred method for obtaining information. Such interviews elicit details about the reason for the referral, current difficulties, traumatic events; temperament; family, medical and developmental history; and physical, cognitive, emotional, and social development. Child/caregiver interactions warrant observation, as does the child when playing alone and with other children. Standardized instruments are used for these evaluations.

Dr. Harrison reported that she has no relevant financial relationships.

BALTIMORE — There's a growing appreciation among pediatric psychiatrists that mental illnesses occur among preschoolers and that identification and treatment are critical to getting these kids back on track for healthy development, according to Dr. Joyce N. Harrison, director of Preschool Clinical Programs at Johns Hopkins Bayview Medical Center in Baltimore.

“When I was in training 15 years ago, I thought all psychiatric disorders started at age 6 because that's when we started seeing kids, but we've begun to see kids younger and younger,” she said at a meeting on developmental disabilities sponsored by Johns Hopkins University.

Around 10% of preschoolers are believed to have a severe impairing psychiatric disorder; rates of attention-deficit/hyperactivity disorder, disruptive behavior disorders, depression, and anxiety in preschool children are estimated at 3%, 8%, 2%, and 9%, respectively.

Symptoms of these disorders can interfere with parent-child relationships, family functioning, social development, the ability to participate in child care, and with learning and school readiness.

“We have a very narrow window to get them back on the developmental trajectory,” she said. During early childhood, brain development is rapid and attachment to caregivers is critical. All learning occurs within the context of relationships and life experiences have a profound effect on later development.

Nationally, early care and education providers report that challenging behavior and problems with social skills are their greatest challenge; preschoolers are expelled at a rate three times higher than that for school-aged children, according to Dr. Harrison.

In 2006–2007, 67% of the referrals to the Michigan Child Care Expulsion Prevention Initiative were for children aged 0–3 years. That state-funded project is aimed at supporting the mental health needs of children ages 0–5 years. Children are referred to the program for frequent aggressive behavior such as biting, or for developmental concerns.

An estimated 10%–15% of children aged 1–2 years have significant social-emotional problems, according to Dr. Harrison. “The prevalence of social/emotional behavior problems in preschoolers is almost at epidemic proportions,” Dr. Harrison said.

“A stereotypical presentation in my clinic is a kid who is aggressive and they don't sleep and they're out of control or they're hyperactive,” Dr. Harrison said. “My approach is that it's a disruptive behavior disorder until proven otherwise, until we can get at what's underneath the behavior,” she said.

The evaluation process usually requires three to five sessions, and family interviews are the preferred method for obtaining information. Such interviews elicit details about the reason for the referral, current difficulties, traumatic events; temperament; family, medical and developmental history; and physical, cognitive, emotional, and social development. Child/caregiver interactions warrant observation, as does the child when playing alone and with other children. Standardized instruments are used for these evaluations.

Dr. Harrison reported that she has no relevant financial relationships.

WASHINGTON — The use of statins was associated with a 33% reduction in the risk of emergency department visits and hospitalizations among adult asthma patients in a retrospective study.

Statin use during the previous 12 months was independently associated with a significant 33% relative risk reduction for recurrent asthma-related ED/hospitalization events over 12 months, Eric Stanek, Pharm.D., reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Dr. Stanek, a researcher at Medco Health Solutions Inc., and his colleagues used data from the Medco National Integrated Database, which includes more than 12 million individuals. Adult patients were included if they had received index inhaled corticosteroid therapy between January and December 2006, and had at least one ED/hospitalization visit for asthma in the 12 months prior to the index steroid prescription.

The study included 6,574 patients, of whom 2,103 had received concomitant statin therapy. The most commonly prescribed statin was atorvastatin (42%), followed by simvastatin (25%).

In a univariate analysis, the incidence of ED/hospitalization events was 29.4% in statin-unexposed patients and 20.5% in statin-exposed patients (odds ratio 0.62). The odds ratio was 0.67 in a multivariate analysis that adjusted for age, sex, previous asthma events, and asthma therapy. Both differences were significant.

The findings support the hypothesis that “statins may improve clinical outcomes in adults with asthma, and provide a good basis for additional prospective investigation,” Dr. Stanek said.

Dr. Stanek reported that he has no relevant financial conflicts of interest, but noted that his employer, Medco Health Solutions Inc., has contracts with several pharmaceutical companies.

WASHINGTON — The use of statins was associated with a 33% reduction in the risk of emergency department visits and hospitalizations among adult asthma patients in a retrospective study.

Statin use during the previous 12 months was independently associated with a significant 33% relative risk reduction for recurrent asthma-related ED/hospitalization events over 12 months, Eric Stanek, Pharm.D., reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Dr. Stanek, a researcher at Medco Health Solutions Inc., and his colleagues used data from the Medco National Integrated Database, which includes more than 12 million individuals. Adult patients were included if they had received index inhaled corticosteroid therapy between January and December 2006, and had at least one ED/hospitalization visit for asthma in the 12 months prior to the index steroid prescription.

The study included 6,574 patients, of whom 2,103 had received concomitant statin therapy. The most commonly prescribed statin was atorvastatin (42%), followed by simvastatin (25%).

In a univariate analysis, the incidence of ED/hospitalization events was 29.4% in statin-unexposed patients and 20.5% in statin-exposed patients (odds ratio 0.62). The odds ratio was 0.67 in a multivariate analysis that adjusted for age, sex, previous asthma events, and asthma therapy. Both differences were significant.

The findings support the hypothesis that “statins may improve clinical outcomes in adults with asthma, and provide a good basis for additional prospective investigation,” Dr. Stanek said.

Dr. Stanek reported that he has no relevant financial conflicts of interest, but noted that his employer, Medco Health Solutions Inc., has contracts with several pharmaceutical companies.

WASHINGTON — The use of statins was associated with a 33% reduction in the risk of emergency department visits and hospitalizations among adult asthma patients in a retrospective study.

Statin use during the previous 12 months was independently associated with a significant 33% relative risk reduction for recurrent asthma-related ED/hospitalization events over 12 months, Eric Stanek, Pharm.D., reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Dr. Stanek, a researcher at Medco Health Solutions Inc., and his colleagues used data from the Medco National Integrated Database, which includes more than 12 million individuals. Adult patients were included if they had received index inhaled corticosteroid therapy between January and December 2006, and had at least one ED/hospitalization visit for asthma in the 12 months prior to the index steroid prescription.

The study included 6,574 patients, of whom 2,103 had received concomitant statin therapy. The most commonly prescribed statin was atorvastatin (42%), followed by simvastatin (25%).

In a univariate analysis, the incidence of ED/hospitalization events was 29.4% in statin-unexposed patients and 20.5% in statin-exposed patients (odds ratio 0.62). The odds ratio was 0.67 in a multivariate analysis that adjusted for age, sex, previous asthma events, and asthma therapy. Both differences were significant.

The findings support the hypothesis that “statins may improve clinical outcomes in adults with asthma, and provide a good basis for additional prospective investigation,” Dr. Stanek said.

Dr. Stanek reported that he has no relevant financial conflicts of interest, but noted that his employer, Medco Health Solutions Inc., has contracts with several pharmaceutical companies.

WASHINGTON — Group drop-in appointments reduce emergency department visits and rescue medicine use in adult patients with asthma, according to the results of a small study.

ED and hospital use was reduced 40%, and the average use of rescue medication decreased by half over a 4-year period among patients seen as part of a weekly drop-in group, Dr. Myron Liebhaber reported in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In addition, nocturnal waking was reduced from 4 to 1.5 times per month.

The drop-in group medical appointments were provided for adult patients with chronic asthma, wrote Dr. Liebhaber, an allergist in Santa Barbara, Calif. The program was designed to allow physicians to evaluate patients with asthma on a weekly basis and to provide patients with asthma education.

Groups were limited to 10 patients, and the appointments typically lasted for 90 minutes. The appointment process proceeded in three steps: vital signs and spirometry (with a nurse), an interim brief history and a physical exam (with a physician), and a group session (with an asthma educator and a behaviorist).

The study included 64 adults, who were followed for 4 years. In all, 42 patients continued the program for 4 years and were considered regular attendees.

A total of 26 patients completed the baseline and 1-year Asthma Quality of Life Questionnaire; scores improved by 373 points in the first year, with most improvement in the symptoms domain.

Dr. Liebhaber reported that he had no relevant financial relationships.

WASHINGTON — Group drop-in appointments reduce emergency department visits and rescue medicine use in adult patients with asthma, according to the results of a small study.

ED and hospital use was reduced 40%, and the average use of rescue medication decreased by half over a 4-year period among patients seen as part of a weekly drop-in group, Dr. Myron Liebhaber reported in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In addition, nocturnal waking was reduced from 4 to 1.5 times per month.

The drop-in group medical appointments were provided for adult patients with chronic asthma, wrote Dr. Liebhaber, an allergist in Santa Barbara, Calif. The program was designed to allow physicians to evaluate patients with asthma on a weekly basis and to provide patients with asthma education.

Groups were limited to 10 patients, and the appointments typically lasted for 90 minutes. The appointment process proceeded in three steps: vital signs and spirometry (with a nurse), an interim brief history and a physical exam (with a physician), and a group session (with an asthma educator and a behaviorist).

The study included 64 adults, who were followed for 4 years. In all, 42 patients continued the program for 4 years and were considered regular attendees.

A total of 26 patients completed the baseline and 1-year Asthma Quality of Life Questionnaire; scores improved by 373 points in the first year, with most improvement in the symptoms domain.

Dr. Liebhaber reported that he had no relevant financial relationships.

WASHINGTON — Group drop-in appointments reduce emergency department visits and rescue medicine use in adult patients with asthma, according to the results of a small study.

ED and hospital use was reduced 40%, and the average use of rescue medication decreased by half over a 4-year period among patients seen as part of a weekly drop-in group, Dr. Myron Liebhaber reported in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In addition, nocturnal waking was reduced from 4 to 1.5 times per month.

The drop-in group medical appointments were provided for adult patients with chronic asthma, wrote Dr. Liebhaber, an allergist in Santa Barbara, Calif. The program was designed to allow physicians to evaluate patients with asthma on a weekly basis and to provide patients with asthma education.

Groups were limited to 10 patients, and the appointments typically lasted for 90 minutes. The appointment process proceeded in three steps: vital signs and spirometry (with a nurse), an interim brief history and a physical exam (with a physician), and a group session (with an asthma educator and a behaviorist).

The study included 64 adults, who were followed for 4 years. In all, 42 patients continued the program for 4 years and were considered regular attendees.

A total of 26 patients completed the baseline and 1-year Asthma Quality of Life Questionnaire; scores improved by 373 points in the first year, with most improvement in the symptoms domain.

Dr. Liebhaber reported that he had no relevant financial relationships.

WASHINGTON — A filaggrin mutation appears to confer susceptibility to atopic dermatitis complicated by eczema herpeticum, study results showed.

In a genotyping study, single-locus association tests revealed that filaggrin R501X null mutation is significantly associated with atopic dermatitis (AD) and atopic dermatitis complicated with eczema herpeticum (ADEH) in white and black patients, Kathleen C. Barnes, Ph.D., said in a poster presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

"This study of filaggrin polymorphisms suggests the functional R501X mutation, in addition to AD risk, confers an added risk of ADEH, with an estimated effect size of nearly 12 [OR = 11.8] among [white] patients," the researchers wrote. Notably, this is the first study demonstrating an association between filaggrin polymorphisms and the risk of AD and associated traits in blacks, according to Dr. Barnes of the division of allergy and clinical immunology at Johns Hopkins University in Baltimore.

The study included 414 white patients with atopy (165 with AD, 93 with ADEH, and 156 nonatopic controls) and 328 black patients (155 with AD, 21 with ADEH, and 152 nonatopic controls). AD was diagnosed using the U.S. consensus criteria. ADEH was defined as AD with at least one documented episode of eczema herpeticum. Total serum IgE levels were measured and eczema severity was assessed using the eczema area and severity index grading system.

The R501X null mutation was genotyped using the TaqMan allelic discrimination assay. In addition, the 2282del4 mutation was genotyped using an ABI 3700 sequencer. Nine tagging single-nucleotide polymorphisms were genotyped.

The researchers found significant associations between the 2282del4 mutation and AD, with allele frequencies of 10.7% among all AD patients, compared with 5.6% among controls. However, no association was observed when the analysis was limited to the patients with ADEH. Also, no associations were observed between 2282del4 and AD or ADEH among blacks, likely because of the low frequency among healthy controls (less than 1%) and AD patients (6%) and the complete absence among ADEH patients.

"The relationship between this null mutation and disease might be related to an increased propensity to disseminated viral skin infections resulting from skin barrier dysfunction," the researchers speculated.

Dr. Barnes reported having no relevant financial relationships.

WASHINGTON — A filaggrin mutation appears to confer susceptibility to atopic dermatitis complicated by eczema herpeticum, study results showed.

In a genotyping study, single-locus association tests revealed that filaggrin R501X null mutation is significantly associated with atopic dermatitis (AD) and atopic dermatitis complicated with eczema herpeticum (ADEH) in white and black patients, Kathleen C. Barnes, Ph.D., said in a poster presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

"This study of filaggrin polymorphisms suggests the functional R501X mutation, in addition to AD risk, confers an added risk of ADEH, with an estimated effect size of nearly 12 [OR = 11.8] among [white] patients," the researchers wrote. Notably, this is the first study demonstrating an association between filaggrin polymorphisms and the risk of AD and associated traits in blacks, according to Dr. Barnes of the division of allergy and clinical immunology at Johns Hopkins University in Baltimore.

The study included 414 white patients with atopy (165 with AD, 93 with ADEH, and 156 nonatopic controls) and 328 black patients (155 with AD, 21 with ADEH, and 152 nonatopic controls). AD was diagnosed using the U.S. consensus criteria. ADEH was defined as AD with at least one documented episode of eczema herpeticum. Total serum IgE levels were measured and eczema severity was assessed using the eczema area and severity index grading system.

The R501X null mutation was genotyped using the TaqMan allelic discrimination assay. In addition, the 2282del4 mutation was genotyped using an ABI 3700 sequencer. Nine tagging single-nucleotide polymorphisms were genotyped.

The researchers found significant associations between the 2282del4 mutation and AD, with allele frequencies of 10.7% among all AD patients, compared with 5.6% among controls. However, no association was observed when the analysis was limited to the patients with ADEH. Also, no associations were observed between 2282del4 and AD or ADEH among blacks, likely because of the low frequency among healthy controls (less than 1%) and AD patients (6%) and the complete absence among ADEH patients.

"The relationship between this null mutation and disease might be related to an increased propensity to disseminated viral skin infections resulting from skin barrier dysfunction," the researchers speculated.

Dr. Barnes reported having no relevant financial relationships.

WASHINGTON — A filaggrin mutation appears to confer susceptibility to atopic dermatitis complicated by eczema herpeticum, study results showed.

In a genotyping study, single-locus association tests revealed that filaggrin R501X null mutation is significantly associated with atopic dermatitis (AD) and atopic dermatitis complicated with eczema herpeticum (ADEH) in white and black patients, Kathleen C. Barnes, Ph.D., said in a poster presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

"This study of filaggrin polymorphisms suggests the functional R501X mutation, in addition to AD risk, confers an added risk of ADEH, with an estimated effect size of nearly 12 [OR = 11.8] among [white] patients," the researchers wrote. Notably, this is the first study demonstrating an association between filaggrin polymorphisms and the risk of AD and associated traits in blacks, according to Dr. Barnes of the division of allergy and clinical immunology at Johns Hopkins University in Baltimore.

The study included 414 white patients with atopy (165 with AD, 93 with ADEH, and 156 nonatopic controls) and 328 black patients (155 with AD, 21 with ADEH, and 152 nonatopic controls). AD was diagnosed using the U.S. consensus criteria. ADEH was defined as AD with at least one documented episode of eczema herpeticum. Total serum IgE levels were measured and eczema severity was assessed using the eczema area and severity index grading system.

The R501X null mutation was genotyped using the TaqMan allelic discrimination assay. In addition, the 2282del4 mutation was genotyped using an ABI 3700 sequencer. Nine tagging single-nucleotide polymorphisms were genotyped.

The researchers found significant associations between the 2282del4 mutation and AD, with allele frequencies of 10.7% among all AD patients, compared with 5.6% among controls. However, no association was observed when the analysis was limited to the patients with ADEH. Also, no associations were observed between 2282del4 and AD or ADEH among blacks, likely because of the low frequency among healthy controls (less than 1%) and AD patients (6%) and the complete absence among ADEH patients.

"The relationship between this null mutation and disease might be related to an increased propensity to disseminated viral skin infections resulting from skin barrier dysfunction," the researchers speculated.

Dr. Barnes reported having no relevant financial relationships.

WASHINGTON — Allergies to peanuts, eggs, and dust mites significantly increase the risk of persistent atopic dermatitis, study results showed.

Pediatric patients with a peanut allergy (OR = 2.9), egg allergy (OR = 2.7), or dust mite allergy (OR = 4.0) were significantly more likely to have persistent atopic dermatitis (AD) than were those without these factors in a study of 177 patients, reported Dr. Ejaz Yousef, chief of pediatric allergy and immunology at the Alfred I. duPont Hospital for Children in Wilmington, Del.

Patients aged 5-18 years were assessed for potential predictors of persistent AD, including race, age at onset, age of solid food introduction, whether the patients were breastfed, smoke exposure, coincident infection, other atopic disease, peripheral eosinophilia, and total IgE level. Predictors were compared with AD remission versus persistence status.

Among the patients, 76% were considered to have persistent disease. No other variables were significantly associated with AD persistence, although there was a trend toward increased risk of persistent disease in those with exposure to tobacco smoke and peripheral eosinophilia, Dr. Yousef said in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The findings highlight "the importance of determining the presence of these risk factors in patients with AD, and [of taking] steps to modify those that can be modified" wrote Dr. Yousef.

Dr. Yousef reported having no relevant financial relationships.

WASHINGTON — Allergies to peanuts, eggs, and dust mites significantly increase the risk of persistent atopic dermatitis, study results showed.

Pediatric patients with a peanut allergy (OR = 2.9), egg allergy (OR = 2.7), or dust mite allergy (OR = 4.0) were significantly more likely to have persistent atopic dermatitis (AD) than were those without these factors in a study of 177 patients, reported Dr. Ejaz Yousef, chief of pediatric allergy and immunology at the Alfred I. duPont Hospital for Children in Wilmington, Del.

Patients aged 5-18 years were assessed for potential predictors of persistent AD, including race, age at onset, age of solid food introduction, whether the patients were breastfed, smoke exposure, coincident infection, other atopic disease, peripheral eosinophilia, and total IgE level. Predictors were compared with AD remission versus persistence status.

Among the patients, 76% were considered to have persistent disease. No other variables were significantly associated with AD persistence, although there was a trend toward increased risk of persistent disease in those with exposure to tobacco smoke and peripheral eosinophilia, Dr. Yousef said in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The findings highlight "the importance of determining the presence of these risk factors in patients with AD, and [of taking] steps to modify those that can be modified" wrote Dr. Yousef.

Dr. Yousef reported having no relevant financial relationships.

WASHINGTON — Allergies to peanuts, eggs, and dust mites significantly increase the risk of persistent atopic dermatitis, study results showed.

Pediatric patients with a peanut allergy (OR = 2.9), egg allergy (OR = 2.7), or dust mite allergy (OR = 4.0) were significantly more likely to have persistent atopic dermatitis (AD) than were those without these factors in a study of 177 patients, reported Dr. Ejaz Yousef, chief of pediatric allergy and immunology at the Alfred I. duPont Hospital for Children in Wilmington, Del.

Patients aged 5-18 years were assessed for potential predictors of persistent AD, including race, age at onset, age of solid food introduction, whether the patients were breastfed, smoke exposure, coincident infection, other atopic disease, peripheral eosinophilia, and total IgE level. Predictors were compared with AD remission versus persistence status.

Among the patients, 76% were considered to have persistent disease. No other variables were significantly associated with AD persistence, although there was a trend toward increased risk of persistent disease in those with exposure to tobacco smoke and peripheral eosinophilia, Dr. Yousef said in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The findings highlight "the importance of determining the presence of these risk factors in patients with AD, and [of taking] steps to modify those that can be modified" wrote Dr. Yousef.

Dr. Yousef reported having no relevant financial relationships.

WASHINGTON — The use of statins was associated with a 33% reduction in the risk of emergency department visits and hospitalizations among adult asthma patients in a retrospective study of more than 6,500 patients.

Statin use in the previous 12 months was independently associated with a significant 33% relative risk reduction for recurrent asthma-related ED/hospitalization events over 12 months.

The findings were based on a model that adjusted for factors such as age, gender, ED/hospitalization events in the prior 12 months, and asthma therapy in the prior 12 months, Eric Stanek, Pharm.D., reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Dr. Stanek of Medco Health Solutions Inc. and his colleagues used data from the Medco National Integrated Database, which includes more than 12 million individuals. Adult patients were included if they had received index inhaled corticosteroid therapy between January 2006 and December 2006, and if they had at least one ED/hospital visit for asthma in the 12 months before the index steroid prescription.

The study included 6,574 patients, of whom 2,103 had received concomitant statin therapy. The statin group was older, more likely to be male, and less likely to have had at least two asthma ED/hospitalization events in the previous 12 months. The most commonly prescribed statin was atorvastatin (42%), followed by simvastatin (25%).

In a univariate analysis, incidence of ED/hospitalization events was 29.4% in statin-unexposed patients and 20.5% in statin-exposed patients (odds ratio 0.62). The odds ratio was 0.67 in a multivariate analysis.

Statins are thought to exert anti-inflammatory effects that may have a positive impact on asthma. The findings support the hypothesis that “statins may improve clinical outcomes in adults with asthma,” Dr. Stanek said.

Dr. Stanek reported that he has no relevant financial conflicts of interest, but noted that his employer, Medco Health Solutions Inc., has contracts with several pharmaceutical companies.

WASHINGTON — The use of statins was associated with a 33% reduction in the risk of emergency department visits and hospitalizations among adult asthma patients in a retrospective study of more than 6,500 patients.

Statin use in the previous 12 months was independently associated with a significant 33% relative risk reduction for recurrent asthma-related ED/hospitalization events over 12 months.

The findings were based on a model that adjusted for factors such as age, gender, ED/hospitalization events in the prior 12 months, and asthma therapy in the prior 12 months, Eric Stanek, Pharm.D., reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Dr. Stanek of Medco Health Solutions Inc. and his colleagues used data from the Medco National Integrated Database, which includes more than 12 million individuals. Adult patients were included if they had received index inhaled corticosteroid therapy between January 2006 and December 2006, and if they had at least one ED/hospital visit for asthma in the 12 months before the index steroid prescription.

The study included 6,574 patients, of whom 2,103 had received concomitant statin therapy. The statin group was older, more likely to be male, and less likely to have had at least two asthma ED/hospitalization events in the previous 12 months. The most commonly prescribed statin was atorvastatin (42%), followed by simvastatin (25%).

In a univariate analysis, incidence of ED/hospitalization events was 29.4% in statin-unexposed patients and 20.5% in statin-exposed patients (odds ratio 0.62). The odds ratio was 0.67 in a multivariate analysis.

Statins are thought to exert anti-inflammatory effects that may have a positive impact on asthma. The findings support the hypothesis that “statins may improve clinical outcomes in adults with asthma,” Dr. Stanek said.

Dr. Stanek reported that he has no relevant financial conflicts of interest, but noted that his employer, Medco Health Solutions Inc., has contracts with several pharmaceutical companies.

WASHINGTON — The use of statins was associated with a 33% reduction in the risk of emergency department visits and hospitalizations among adult asthma patients in a retrospective study of more than 6,500 patients.

Statin use in the previous 12 months was independently associated with a significant 33% relative risk reduction for recurrent asthma-related ED/hospitalization events over 12 months.

The findings were based on a model that adjusted for factors such as age, gender, ED/hospitalization events in the prior 12 months, and asthma therapy in the prior 12 months, Eric Stanek, Pharm.D., reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Dr. Stanek of Medco Health Solutions Inc. and his colleagues used data from the Medco National Integrated Database, which includes more than 12 million individuals. Adult patients were included if they had received index inhaled corticosteroid therapy between January 2006 and December 2006, and if they had at least one ED/hospital visit for asthma in the 12 months before the index steroid prescription.

The study included 6,574 patients, of whom 2,103 had received concomitant statin therapy. The statin group was older, more likely to be male, and less likely to have had at least two asthma ED/hospitalization events in the previous 12 months. The most commonly prescribed statin was atorvastatin (42%), followed by simvastatin (25%).

In a univariate analysis, incidence of ED/hospitalization events was 29.4% in statin-unexposed patients and 20.5% in statin-exposed patients (odds ratio 0.62). The odds ratio was 0.67 in a multivariate analysis.

Statins are thought to exert anti-inflammatory effects that may have a positive impact on asthma. The findings support the hypothesis that “statins may improve clinical outcomes in adults with asthma,” Dr. Stanek said.

Dr. Stanek reported that he has no relevant financial conflicts of interest, but noted that his employer, Medco Health Solutions Inc., has contracts with several pharmaceutical companies.

Updated guidelines on heart failure issued by the American College of Cardiology and the American Heart Association include new recommendations on managing hospitalized patients and strengthened guidance on the use of hydralazine and isosorbine dinitrate in African Americans.

Heart failure, the leading cause of hospitalization of patients over age 65 years, “is responsible for a huge portion of the costs associated with cardiovascular disease,” Dr. Mariell Jessup, chair of the group that wrote the guidelines, noted in a statement.

“These guidelines strive to reflect the most recent information coming out of the clinical trials on heart failure,” said Dr. Jessup, who is a professor of medicine and director of the heart failure and transplant program at the University of Pennsylvania in Philadelphia.

Developed as a consensus of expert opinion based on review of late-breaking clinical trials and other data, the 2009 focused update was published in the Journal of the American College of Cardiology (J. Am. Coll. Cardiol. 2009;53:1353–82) and in Circulation.

The new section on the management of hospitalized patients with acute heart failure was developed in response to the growing importance of the topic. “A number of recent HF trials reviewed for this update were, in fact, performed on hospitalized patients, and a number of newer therapies are under development for this population. Moreover, there is increasing government and other third-party payer interest in the prevention of HF hospitalizations and rehospitalization,” the writing committee noted.

The section on hospital care includes guidance on establishing etiology, assessments that should be performed, and guidance on transitioning of patients to home care, including a new medication regimen and a plan for detecting signs that warrant immediate medical attention.

The update strengthens recommendations on using the combination of hydralazine and isosorbide dinitrate in African American patients, citing clinical trial evidence that this patient population benefits from the addition of this combination to standard therapy with an ACE inhibitor and/or a beta blocker.

“This combination is recommended for African Americans who remain symptomatic despite optimal medical therapy,” according to the update, developed in collaboration with the International Society for Heart and Lung Transplantation.

The guidelines also provide streamlined information on using implantable cardioverter defibrillators and cardiac resynchronization devices, and clarify treatment goals in patients who have both heart failure and atrial fibrillation.

In addition, the update clarifies the use of testing for natriuretic peptides (B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide) for evaluating risk in patients in the urgent care setting, and upgrades the level of evidence against routine intermittent infusions of vasoactive drugs and positive inotropic drugs for patients with refractory end-stage heart failure.

The new guidelines represent a focused revision of comprehensive recommendations that were issued in 2005. The focused update process allows updates to be published on an as-needed basis, based on review of evidence at least twice a year. Recommendations on heart failure management that are not addressed in the update remain current.

Dr. Jessup reported that she was a consultant for Acorn, CardioMEMS, GlaxoSmithKline, Medtronic, Scios, and Ventracor. The other members of the guideline group also reported potential conflicts of interest with various pharmaceutical and medical device companies.

'These guidelines strive to reflect the most recent information coming out of the clinical trials on heart failure.' DR. JESSUP

Updated guidelines on heart failure issued by the American College of Cardiology and the American Heart Association include new recommendations on managing hospitalized patients and strengthened guidance on the use of hydralazine and isosorbine dinitrate in African Americans.

Heart failure, the leading cause of hospitalization of patients over age 65 years, “is responsible for a huge portion of the costs associated with cardiovascular disease,” Dr. Mariell Jessup, chair of the group that wrote the guidelines, noted in a statement.

“These guidelines strive to reflect the most recent information coming out of the clinical trials on heart failure,” said Dr. Jessup, who is a professor of medicine and director of the heart failure and transplant program at the University of Pennsylvania in Philadelphia.

Developed as a consensus of expert opinion based on review of late-breaking clinical trials and other data, the 2009 focused update was published in the Journal of the American College of Cardiology (J. Am. Coll. Cardiol. 2009;53:1353–82) and in Circulation.

The new section on the management of hospitalized patients with acute heart failure was developed in response to the growing importance of the topic. “A number of recent HF trials reviewed for this update were, in fact, performed on hospitalized patients, and a number of newer therapies are under development for this population. Moreover, there is increasing government and other third-party payer interest in the prevention of HF hospitalizations and rehospitalization,” the writing committee noted.

The section on hospital care includes guidance on establishing etiology, assessments that should be performed, and guidance on transitioning of patients to home care, including a new medication regimen and a plan for detecting signs that warrant immediate medical attention.

The update strengthens recommendations on using the combination of hydralazine and isosorbide dinitrate in African American patients, citing clinical trial evidence that this patient population benefits from the addition of this combination to standard therapy with an ACE inhibitor and/or a beta blocker.

“This combination is recommended for African Americans who remain symptomatic despite optimal medical therapy,” according to the update, developed in collaboration with the International Society for Heart and Lung Transplantation.

The guidelines also provide streamlined information on using implantable cardioverter defibrillators and cardiac resynchronization devices, and clarify treatment goals in patients who have both heart failure and atrial fibrillation.

In addition, the update clarifies the use of testing for natriuretic peptides (B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide) for evaluating risk in patients in the urgent care setting, and upgrades the level of evidence against routine intermittent infusions of vasoactive drugs and positive inotropic drugs for patients with refractory end-stage heart failure.

The new guidelines represent a focused revision of comprehensive recommendations that were issued in 2005. The focused update process allows updates to be published on an as-needed basis, based on review of evidence at least twice a year. Recommendations on heart failure management that are not addressed in the update remain current.

Dr. Jessup reported that she was a consultant for Acorn, CardioMEMS, GlaxoSmithKline, Medtronic, Scios, and Ventracor. The other members of the guideline group also reported potential conflicts of interest with various pharmaceutical and medical device companies.

'These guidelines strive to reflect the most recent information coming out of the clinical trials on heart failure.' DR. JESSUP

Updated guidelines on heart failure issued by the American College of Cardiology and the American Heart Association include new recommendations on managing hospitalized patients and strengthened guidance on the use of hydralazine and isosorbine dinitrate in African Americans.

Heart failure, the leading cause of hospitalization of patients over age 65 years, “is responsible for a huge portion of the costs associated with cardiovascular disease,” Dr. Mariell Jessup, chair of the group that wrote the guidelines, noted in a statement.

“These guidelines strive to reflect the most recent information coming out of the clinical trials on heart failure,” said Dr. Jessup, who is a professor of medicine and director of the heart failure and transplant program at the University of Pennsylvania in Philadelphia.

Developed as a consensus of expert opinion based on review of late-breaking clinical trials and other data, the 2009 focused update was published in the Journal of the American College of Cardiology (J. Am. Coll. Cardiol. 2009;53:1353–82) and in Circulation.

The new section on the management of hospitalized patients with acute heart failure was developed in response to the growing importance of the topic. “A number of recent HF trials reviewed for this update were, in fact, performed on hospitalized patients, and a number of newer therapies are under development for this population. Moreover, there is increasing government and other third-party payer interest in the prevention of HF hospitalizations and rehospitalization,” the writing committee noted.

The section on hospital care includes guidance on establishing etiology, assessments that should be performed, and guidance on transitioning of patients to home care, including a new medication regimen and a plan for detecting signs that warrant immediate medical attention.

The update strengthens recommendations on using the combination of hydralazine and isosorbide dinitrate in African American patients, citing clinical trial evidence that this patient population benefits from the addition of this combination to standard therapy with an ACE inhibitor and/or a beta blocker.

“This combination is recommended for African Americans who remain symptomatic despite optimal medical therapy,” according to the update, developed in collaboration with the International Society for Heart and Lung Transplantation.

The guidelines also provide streamlined information on using implantable cardioverter defibrillators and cardiac resynchronization devices, and clarify treatment goals in patients who have both heart failure and atrial fibrillation.

In addition, the update clarifies the use of testing for natriuretic peptides (B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide) for evaluating risk in patients in the urgent care setting, and upgrades the level of evidence against routine intermittent infusions of vasoactive drugs and positive inotropic drugs for patients with refractory end-stage heart failure.

The new guidelines represent a focused revision of comprehensive recommendations that were issued in 2005. The focused update process allows updates to be published on an as-needed basis, based on review of evidence at least twice a year. Recommendations on heart failure management that are not addressed in the update remain current.

Dr. Jessup reported that she was a consultant for Acorn, CardioMEMS, GlaxoSmithKline, Medtronic, Scios, and Ventracor. The other members of the guideline group also reported potential conflicts of interest with various pharmaceutical and medical device companies.

'These guidelines strive to reflect the most recent information coming out of the clinical trials on heart failure.' DR. JESSUP

WASHINGTON — Group drop-in appointments reduce emergency department visits and rescue medicine use in adult patients with asthma, according to the results of a small study.

ED and hospital use was reduced 40%, and the average use of rescue medication decreased by half over a 4-year period among patients seen as part of a weekly drop-in group, Dr. Myron Liebhaber reported in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In addition, nocturnal waking was reduced from 4 to 1.5 times per month.

The drop-in group medical appointments were provided for adult patients with chronic asthma, who were encouraged to attend group discussions, wrote Dr. Liebhaber, an allergist in Santa Barbara, Calif. The program was designed to allow physicians to evaluate patients with asthma on a weekly basis and to provide patients with asthma education.

Groups were limited to 10 patients, and the appointments typically lasted for 90 minutes. The appointment process proceeded in three steps: vital signs and spirometry (with a nurse), an interim brief history and a physical exam (with a physician), and a group session (with an asthma educator and a behaviorist).

The study included 64 adults, who were followed for 4 years. Patients performed spirometry and completed an analog scale to measure compliance and satisfaction with care. An Asthma Control Test was also administered at each visit; results were discussed by the group to address concerns. In all, 42 patients continued the program for 4 years and were considered regular attendees.

The Asthma Quality of Life Questionnaire (AQLQ) was used to assess patients' perceptions of disease before the first visit and at 1 year later. The AQLQ assesses perceptions of activity limitation, symptoms, emotional function, and environmental exposure. Twenty-six patients completed the baseline and 1-year AQLQ; scores improved by 373 points in the first year, with the best improvement seen in the symptoms domain.

Dr. Liebhaber reported having no relevant financial relationships.

WASHINGTON — Group drop-in appointments reduce emergency department visits and rescue medicine use in adult patients with asthma, according to the results of a small study.

ED and hospital use was reduced 40%, and the average use of rescue medication decreased by half over a 4-year period among patients seen as part of a weekly drop-in group, Dr. Myron Liebhaber reported in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In addition, nocturnal waking was reduced from 4 to 1.5 times per month.

The drop-in group medical appointments were provided for adult patients with chronic asthma, who were encouraged to attend group discussions, wrote Dr. Liebhaber, an allergist in Santa Barbara, Calif. The program was designed to allow physicians to evaluate patients with asthma on a weekly basis and to provide patients with asthma education.

Groups were limited to 10 patients, and the appointments typically lasted for 90 minutes. The appointment process proceeded in three steps: vital signs and spirometry (with a nurse), an interim brief history and a physical exam (with a physician), and a group session (with an asthma educator and a behaviorist).

The study included 64 adults, who were followed for 4 years. Patients performed spirometry and completed an analog scale to measure compliance and satisfaction with care. An Asthma Control Test was also administered at each visit; results were discussed by the group to address concerns. In all, 42 patients continued the program for 4 years and were considered regular attendees.

The Asthma Quality of Life Questionnaire (AQLQ) was used to assess patients' perceptions of disease before the first visit and at 1 year later. The AQLQ assesses perceptions of activity limitation, symptoms, emotional function, and environmental exposure. Twenty-six patients completed the baseline and 1-year AQLQ; scores improved by 373 points in the first year, with the best improvement seen in the symptoms domain.

Dr. Liebhaber reported having no relevant financial relationships.

WASHINGTON — Group drop-in appointments reduce emergency department visits and rescue medicine use in adult patients with asthma, according to the results of a small study.

ED and hospital use was reduced 40%, and the average use of rescue medication decreased by half over a 4-year period among patients seen as part of a weekly drop-in group, Dr. Myron Liebhaber reported in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In addition, nocturnal waking was reduced from 4 to 1.5 times per month.

The drop-in group medical appointments were provided for adult patients with chronic asthma, who were encouraged to attend group discussions, wrote Dr. Liebhaber, an allergist in Santa Barbara, Calif. The program was designed to allow physicians to evaluate patients with asthma on a weekly basis and to provide patients with asthma education.

Groups were limited to 10 patients, and the appointments typically lasted for 90 minutes. The appointment process proceeded in three steps: vital signs and spirometry (with a nurse), an interim brief history and a physical exam (with a physician), and a group session (with an asthma educator and a behaviorist).

The study included 64 adults, who were followed for 4 years. Patients performed spirometry and completed an analog scale to measure compliance and satisfaction with care. An Asthma Control Test was also administered at each visit; results were discussed by the group to address concerns. In all, 42 patients continued the program for 4 years and were considered regular attendees.

The Asthma Quality of Life Questionnaire (AQLQ) was used to assess patients' perceptions of disease before the first visit and at 1 year later. The AQLQ assesses perceptions of activity limitation, symptoms, emotional function, and environmental exposure. Twenty-six patients completed the baseline and 1-year AQLQ; scores improved by 373 points in the first year, with the best improvement seen in the symptoms domain.

Dr. Liebhaber reported having no relevant financial relationships.