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The prevalence and differential diagnosis of rhinitis changes as we progress from birth to senescence. The heavy burden of allergic rhinitis is often overlooked in infants and disregarded in childhood and adolescence. In women, especially during pregnancy, hormonal changes can significantly affect nasal mucosal hyperreactivity and worsen ongoing syndromes. Various types of inflammatory and noninflammatory nonallergic rhinitides become more prevalent in the fifth decade and beyond. The burgeoning elderly population with irritant, atrophic, and medication-related rhinitis will constitute a greater proportion of our practices as the general population ages.

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Vaccines have had a dramatic effect on the prevalence of communicable diseases, but, in selected individuals, the injection presents a risk of anaphylaxis. Fortunately, most people have no allergic reactions to vaccines. In egg-allergic individuals, care must be taken before administering specific vaccines; the algorithm provided in this article gives specific recommendations for skin testing and desensitization. This algorithm is not needed for individuals receiving the measles-mumps-rubella vaccine because the risk of anaphylaxis is extremely low, even in those with known egg-protein sensitivity. Some individuals have gelatin sensitivity, which may cause anaphylaxis. Selected vaccines contain antibiotic drugs, so it is important to note if an individual has any known drug sensitivity, especially to neomycin, polymyxin B, or amphotericin B. Lastly, vaccine preservatives may cause reactions, but this occurs very infrequently.

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BACKGROUND: Hypersensitivity to deer dander is rarely reported, with only 26 cases in the literature. Ours is the youngest reported case and the first reported case of anaphylaxis on exposure to a live deer. OBJECTIVE: Evaluation of a case of anaphylaxis in a young boy upon exposure to a deer. METHODS AND RESULTS: A 4-year-old boy experienced hives, swelling, and shortness of breath requiring epinephrine following a deer exposure. He had one mild reaction 5 days prior to his anaphylaxis with an indirect exposure. A deer dander extract was made from fur supplied by the patient's mother. IgE-mediated reactivity was positive for deer and cattle by both selective skin prick method and RAST results. CONCLUSION: Hypersensitivity to wild animals can lead to life threatening anaphylaxis, even in children. Passive transfer of antigen may occur, but needs further investigation.

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BACKGROUND: Medications containing a combination antihistamine-decongestant are commonly used for allergic rhinitis yet onset-of-action comparisons for symptom relief after a single dose have not been performed. OBJECTIVE: To determine the onset of symptom relief and efficacy of antihistamine-decongestant medications (acrivastine-pseudoephedrine and loratadine-pseudoephedrine) compared with placebo in an outdoor park. METHODS: This study was conducted during the spring of 1997 using a double-blind, placebo-controlled design. Patients completed baseline rhinitis symptom diaries from 7:30 to 9:30 AM. Subjects with qualifying symptom scores received one dose of either acrivastine-pseudoephedrine, loratadine-pseudoephedrine, or placebo at 10:00 AM. Symptom diaries were recorded for the next 4 hours. RESULTS: Of 593 patients randomized to treatment, 592 were included in efficacy analysis. Acrivastine-pseudoephedrine and loratadine-pseudoephedrine demonstrated a mean onset-of-action by 45 and 30 minutes respectively for total symptom and rhinitis symptom scores for the five sites. Onset-of-action for nasal congestion scores was 45 minutes for both medications. Sites having higher pollen exposure (>100 pollen grains over 6 hours) demonstrated a difference between the antihistamine combinations: acrivastine-pseudoephedrine had an onset of action at 45 minutes for total symptom and rhinitis symptom scores, and 15 minutes for nasal congestion scores whereas loratadine-pseudoephedrine had onset-of-action for nasal congestion score of 105 minutes but failed to reach significance at any timepoint for total symptom and rhinitis symptom scores. CONCLUSIONS: Both antihistamine-decongestant combinations demonstrate an onset-of-action within 60 minutes of administration but under conditions of higher pollen exposure, the acrivastine combination was more effective for total symptoms, rhinitis symptoms, and nasal congestion with an onset-of-action within 45 minutes for rhinitis symptoms and 15 minutes for congestion.

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OBJECTIVE: To compare the safety and efficacy of ipratropium bromide 0.03% (IB) with beclomethasone dipropionate 0.042% (BDP) in the treatment of perennial rhinitis in children. METHODS: Thirty-three children with nonallergic perennial rhinitis (NAPR) and 113 with allergic perennial rhinitis (APR) were randomly assigned to either IB or BDP for 6 months in a single-blind, multicenter protocol in which the physician was blinded to treatment. At each visit, patients and physicians rated symptom control of rhinorrhea, nasal congestion, and sneezing. Patients also completed quality of life questionnaires at baseline and after 6 months of therapy. RESULTS: Both treatments showed a significant improvement in control of rhinorrhea, congestion, and sneezing compared with baseline over the 6 months of treatment (P < .05). Only for the control of sneezing was BDP consistently better than IB (P < .05). Among the patients given IB, 61% to 73% assessed the control of rhinorrhea as good or excellent on different study visit days, 43% to 60% similarly rated the control of nasal congestion, and 39% to 43% the control of sneezing. The results for BDP were 68% to 78% for the control of rhinorrhea, 55% to 72% for the control of nasal congestion, and 54% to 68% for the control of sneezing. Quality of life assessment documented that both drugs significantly reduced interference with daily activities and disturbance of mood due to rhinorrhea compared with baseline (P < .05). Both treatments were well tolerated with IB causing less nasal bleeding and irritation than BDP. CONCLUSIONS: Ipratropium bromide was safe and effective in controlling rhinorrhea and diminishing the interference by rhinorrhea in school attendance, concentration on school work, and sleep. Ipratropium bromide was as effective as BDP in the control of rhinorrhea and showed a relatively good effect on congestion. Patient and physician assessment favored BDP in the control of sneezing.

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In 1997, the National Heart, Lung, and Blood Institute released the Second Expert Panel Report on the Guidelines for the Diagnosis and Management of Asthma as a follow-up to the first report issued in 1991. Implementation of the recommendations from this report could have a potentially huge impact on care and treatment of asthma in the United States. Even though the Guidelines are expansive, there are some areas related to the pharmacologic component that warrant further discussion and clarification. These are: (1) safety and efficacy of available asthma medications, (2) clinical efficacy comparisons of inhaled corticosteroids, (3) comparative risks among inhaled corticosteroids, and (4) expectations of different delivery systems used with inhaled corticosteroids.

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BACKGROUND: Anticholinergic agents, specifically the quaternary salt of atropine, are currently being recommended for chronic rhinitis and the common cold. OBJECTIVE: To evaluate the efficacy and safety of 50- and 75-microg doses of atropine sulfate as a nasal spray in perennial allergic rhinitis. METHODS: A placebo-controlled, double-blind study compared 2 doses of atropine nasal spray given 4 times daily for 2 weeks to 45 patients with perennial allergic rhinitis after a 2-week baseline period. RESULTS: Both concentrations of atropine nasal spray improved the severity of rhinorrhea and postnasal drip (P<.001) as reported by patients and physicians. The duration of action in reducing rhinorrhea and postnasal drip for atropine was 2 to 3 hours, compared with less than 1 hour for placebo (P<.01). No difference was noted in efficacy between the 2 atropine doses nor in frequency of adverse events with atropine nasal spray and placebo. CONCLUSIONS: Atropine sulfate, 50 or 75 microg 4 times daily, is effective in reducing rhinorrhea and postnasal drip within 2 weeks and may be an alternative therapy for the rhinorrhea component of rhinitis.

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The effects of the new ipratropium bromide nasal spray on rhinorrhea associated with perennial allergic rhinitis were studied in 219 patients over eight weeks in a multicenter, randomized, double-blind trial. The purpose of the study was to determine whether the new spray reduces nasal hypersecretion in allergic patients without causing excessive dryness or other potential cholinergic side effects. The investigators compared two doses of the spray (42 or 84 mcg/nostril t.i.d.) to placebo. Two hundred and nineteen patients were admitted to the study; 176 completed it. Study design included one week of screening to confirm a diagnosis of perennial allergic rhinitis with clinically significant rhinorrhea, one week of single-blind treatment with a placebo consisting of the saline vehicle of the spray, an eight-week double-blind treatment-comparison period, and one week of follow-up without treatment. Both doses of ipratropium bromide nasal spray significantly reduced the hypersecretion associated with PAR, compared with placebo. The two doses of active drug were equally effective. Treatment differences were noticeable during the first week and remained relatively stable during the eight-week treatment period. There was no evidence of nasal rebound after discontinuation of treatment. The incidence of side effects was comparable to placebo. The spray was well-tolerated, and was not associated with any significant adverse events.

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The objective of this study was to compare the efficacy and safety of Claritin-D 24 Hour (once daily) with that of Claritin-D 12 Hour (twice daily) and placebo in the treatment of patients with seasonal allergic rhinitis (SAR). In this double-blind, placebo-controlled, multicenter study, 469 patients with moderate-to-severe SAR symptoms were treated for 2 weeks with one of the following: Claritin-D 24 Hour (a combination tablet formulation of loratadine 10 mg in the coating and pseudoephedrine sulfate 240 mg in an extended-release core), Claritin-D 12 Hour (a combination tablet formulation of loratadine 5 mg in the tablet coating and 120 mg pseudoephedrine sulfate, 60 mg in the coating and 60 mg in the core), or placebo. Claritin-D 24 Hour and Claritin-D 12 Hour were consistently superior to placebo (P < 0.01) in reducing total, nasal, and nonnasal symptom scores. Patients in the Claritin-D 24 Hour and Claritin-D 12 Hour groups also had significantly greater (P

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The purpose of this study was to assess the safety and efficacy of ipratropium bromide nasal spray 0.06% (aqueous solution), 84 micrograms per nostril three times a day, in reducing nasal hypersecretion in the long-term treatment of patients with perennial allergic rhinitis (PAR). This was an open-label 1-year trial. In the first 6 months all patients were treated with two puffs ipratropium bromide nasal spray 0.06%, 84 micrograms per nostril three times per day, unless they were unable to tolerate the dose. In the last 6 months the dose could be reduced to the lowest amount required to control rhinorrhea. Ninety-six patients entered the trial, and 47 completed it. Sixty-three patients completed more than 6 months of treatment. Patient and physician global evaluation suggested that ipratropium bromide nasal spray 0.06% is effective in controlling rhinorrhea associated with PAR and can contribute to control of congestion, postnasal drip, and sneezing. There was also a trend toward reduction of mucosal edema and improvement in quality of life. The most common drug-related adverse events were nasal dryness, epistaxis/nose bleed, and increased rhinitis. Most adverse events were mild and resulted in drug discontinuation in less than 10% of patients. Ipratropium bromide nasal spray was well tolerated and not associated with serious drug-related adverse events or clinically significant anticholinergic side effects. Use of ipratropium bromide nasal spray alone or with other standard medications should be considered in treating patients with PAR.

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To study the long-term safety and effectiveness of ipratropium bromide nasal spray 0.03% in the treatment of nonallergic perennial rhinitis, we administered this medication for 1 year in an open-label trial involving 285 patients. Our intention was to maintain the highest protocol dose possible to gain a clearer picture of the long-term side effect profile of the compound. Ipratropium bromide was well tolerated with no serious side effects in this patient population. It provided a significant improvement in rhinorrhea throughout the year-long trial; only 17 of 285 patients (6%) were considered treatment failures. There was an improvement in patient quality of life, as well as a substantial reduction in the need for other medications (antihistamines, decongestants, and nasal steroids) used to treat perennial rhinitis symptoms.

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Chronic sinusitis is a recurrent disorder commonly found in atopic individuals, yet few studies have explored the role of inflammatory mediators in sinusitis. Sinus lavage fluid from ten patients with chronic sinusitis obtained during endoscopic surgery was analyzed for total cell counts and then assayed for histamine, immunoreactive leukotriene C4/D4/E4 (LTC4/D4/E4), and prostaglandin D2 (PGD2). All ten patients had been unresponsive to medical treatment, including oral corticosteroids in most cases. High concentrations of histamine, LTC4/D4/E4 and PGD2 were found in sinus fluid and were comparable to levels seen in nasal secretions of allergic rhinitis patients following allergen challenge. In the sinus fluid, inflammatory cells were predominantly neutrophils with only low percentages of mast cells, basophils or eosinophils. On the basis of the histamine and PGD2 concentrations in sinus fluid, we conclude that mast cell/basophil activation does occur in chronic sinusitis and may contribute to the persistent inflammation present in sinusitis.

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Intranasal fluorocarbon anticholinergic agents have been used to treat the nasal hypersecretion of perennial non-allergic rhinitis, but chronic use has been restricted either due to the potential for systemic anticholinergic adverse events or due to the irritating properties of the fluorocarbon metered dose formulations. This study evaluates a new aqueous nasal formulation of ipratropium bromide (Atrovent Nasal Spray 0.03%) in subjects with perennial non-allergic rhinitis in a double-blind, placebo-controlled trial. Two hundred and twenty-eight patients were randomized to receive two sprays per nostril of either ipratropium bromide (42 micrograms/nostril) or placebo-administered three times a day as an aqueous nasal spray over an 8-week interval. Patients were evaluated bi-weekly and maintained daily diaries for duration and severity of nasal symptoms. Ipratropium bromide reduced the mean severity and duration of rhinorrhoea within the first week and throughout the 8 weeks of active treatment compared with placebo (P < 0.05). Secondary endpoints of efficacy (patient and physician global assessments and a quality of life assessment) also supported the use of ipratropium bromide nasal spray for rhinitis symptom control. With the reduction in rhinorrhoea by the ipratropium bromide nasal spray, patients reported a marked improvement in daily moods vs placebo (P < 0.01). Both placebo and ipratropium bromide nasal spray induced a modest reduction of nasal congestion, sneezing and postnasal drip. This improvement in these other nasal symptoms was consistent with the known soothing effects of a nasal saline vehicle. There were no drug-related serious or systemic anticholinergic adverse events.(ABSTRACT TRUNCATED AT 250 WORDS)

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STUDY OBJECTIVE: Local nasal hyperthermia or inhalation of heated water vapor is often recommended as a home remedy for various rhinitis disorders such as the common cold and allergic rhinitis. Inhaled heated vapor treatments and simple saline solution nasal irrigation were investigated for their effect on inflammatory mediator production in nasal secretions. DESIGN: Three treatments were given for nasal irrigation: heated water particles (large particle water vapor) at 43 degrees C, heated molecular water vapor (molecular water vapor) at 41 degrees C, and simple saline solution nasal irrigation. Nasal washes were done before each treatment (baseline), immediately after treatments, and at 30 min, 2, 4, and 6 h. Histamine, prostaglandin D2, and leukotriene C4 (LTC4) concentrations were measured in nasal secretions and compared with baseline values. PATIENTS AND PARTICIPANTS: Thirty symptomatic patients with active perennial allergic rhinitis underwent three treatments at weekly intervals. MEASUREMENTS AND RESULTS: Nasal histamine concentrations fell substantially with the nasal irrigation (p < 0.01 immediately posttreatment and at 30 min; p < 0.05 at 2, 4, and 6 h). Large particle vapor also reduced histamine concentrations for up to 4 h posttreatment compared with baseline values (p < 0.05). Alternatively, molecular water vapor did not alter nasal histamine concentrations. Surprisingly, the three treatments did not alter prostaglandin D2 concentrations over the 6 h. Leukotriene C4 concentrations fell briefly after the large particle treatment but did not with the molecular water vapor. With saline solution irrigation, LTC4 concentrations in nasal secretions were lower than baseline at 30 min to 4 h after a treatment (p < 0.05). CONCLUSIONS: This study demonstrated the usefulness of large particle vapor treatment and saline solution irrigation in reducing inflammatory mediators in nasal secretions and indirectly supports the clinical efficacy of these treatments for chronic rhinitis.

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In egg-sensitive children, measles-mumps-rubella (MMR) vaccination may cause acute allergic reactions; therefore, current recommendations are to perform skin testing with the commercial vaccine before administration to egg-allergic children. In children with positive skin tests, desensitization with the measles-mumps-rubella vaccine should be done in order to administer a full dose of the vaccine. Twelve egg-allergic children, aged 12 months to 5 years of age, were referred to our pediatric allergy clinic for MMR administration over a 20-month period. Three children had positive skin prick or intradermal tests to the MMR vaccine. Two of these three patients experienced systemic hypersensitivity reactions while undergoing desensitization to the MMR. All reactions occurred with injections of the undiluted vaccine. Based upon this experience, we recommend that egg-allergic children should continue to have cutaneous tests done to the MMR vaccine and careful observation during desensitization in those children with positive skin tests.

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The hospitalization and mortality rates incurred from childhood asthma continue to rise despite recent progress into the pathophysiology and treatment of reactive airway disease. We believe that there are specific factors that identify children at risk for death from asthma. The objective of the study was to determine those risk factors that identify children at increased risk for nonfatal, but life-threatening asthma exacerbations resulting in pediatric intensive care unit (PICU) admission. Patients aged 10 months-16 years admitted to Brenner Children's Hospital for status asthmaticus between April 1991 and December 1992 were evaluated with regard to the prevalence of eight different factors using two categories for asthma: (1) life-threatening asthma requiring PICU admission and (2) non-life-threatening asthma requiring routine hospitalization. Risk factors associated with an increased prevalence of non-fatal, but life-threatening asthma requiring PICU sensitivity state. The classification employed here seemed to provide some merits in delineating the features of adulthood asthma.

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