Volume 101, Issue s5

Cold-induced urticaria is a form of physical urticaria that develops on cold exposure in susceptible individuals. The majority of cases have an unknown etiology (primary or idiopathic). In rare forms, it is associated with various disease entities (secondary). The workup of a patient includes a history and physical examination, cold challenge, and a battery of laboratory tests. The management of such patients includes precaution and avoidance measures as well as treatment with antihistamines. Life-threatening symptoms necessitate carrying a self-administered injectable epinephrine.

The frequency of sensitization to environmental antigens changes in different regions. As such, the pattern of sensitivity to common allergens was studied at multiple sites across central Pennsylvania, an area composed of small cities and rural communities, to determine uniqueness of allergies in populations from this area in contrast to allergies as determined by skin testing in large urban centers. The study reported was undertaken to determine allergen variation from an urban population compared with a rural population of a Northeastern state so that environmental avoidance and immunotherapy can be more precisely prescribed. Patient charts were retrospectively reviewed to determine sensitivity to house dust mites (Dermatophagoides pteronyssinus, Dermatophagoides farinae), cockroach, Penicillium, Aspergillus spp, dog, cat, timothy grass, ragweed, oak, and Alternaria tenuis at five sites in Pennsylvania. All of these sites were classified as "small city" or "rural" for the study. One hundred patient records were examined at each site for the results of allergy testing by the prick puncture, radioallergosorbent test (RAST), or intradermal methods. These small-city and rural data were pooled and compared with that of the National Cooperative Inner-City Asthma Study (NCI-CAS), which included 1286 patients from urban environments. The prevalence of allergy to both species of dust mites, dog, timothy grass, and ragweed was significantly greater in the pooled rural group than in the NCICAS inner-city patients (P < .05). In contrast, sensitivity to cockroach antigens and Alternaria was significantly greater in the NCICAS urban population than in the pooled rural group (P < .05). No statistically significant difference was found between the NCICAS and the pooled rural patients in reference to Penicillium, cat, and oak (P > .05).

The complications from untreated sinusitis in a 10-month-old male infant, though at the more severe end of the spectrum, brings to light the importance of diagnosis and treatment even in the very young patient. Acute sinusitis should be diagnosed using established guidelines. Appropriate pharmacologic and osteopathic manipulative treatment should be initiated on diagnosis. Initial antibiotic therapy is a 14-day course of amoxicillin. If the sinusitis fails to resolve, a trial of a second-line antibiotic should be considered. The use of adjunctive medications such as antihistamines, decongestants, and nasal steroids remains controversial. If the patient fails maximal medical therapy, a computed tomography scan and referral to an otolaryngologist for possible surgical intervention should be considered.

In the study reported, the authors examined risk factors for repeated hospital admissions for asthma in a rural/suburban setting. Charts of patients who were hospitalized two or more times with the diagnosis of asthma between June 1991 and January 1998 were reviewed. A questionnaire was completed for each admission for 65 patients. The results demonstrated an equal male-to-female ratio, with a mean age of 27 years. Hispanics represented 12% of the patients although they accounted for only 2.5% of the general population in the area under study. The mean number of hospital admissions was 3.2. A history of depression existed in 25% of the patients. Noncompliance was admitted in 38%. Twenty-five percent were active tobacco smokers. Acknowledged triggers of asthma included viral infections (74%), exercise (50%), weather conditions (43%), dust (38%), cats (36%), sinusitis (32%), pollen (32%), gastroesophageal reflux disease (31%), dogs (30%), smoke (28%), and emotional stress (15%). Medications at time of admission included albuterol (98%), salmeterol xinafoate (26%), theophylline (38%), ipratropium bromide (55%), nedocromil sodium (20%), cromolyn sodium (35%), prednisone (49%), and inhaled corticosteroids (69%). Ninety-five percent had access to a primary care physician. Fifty-seven percent had a pulmonary and 11% had an allergy consult. These data suggest that patients in rural/suburban areas with repeated hospitalizations for asthma have a high probability of noncompliance, depression, and allergenic triggers. Gastroesophageal reflux was a common recognized trigger. Inhaled steroids were underused, whereas ipratropium and theophylline were overused. Bilingual education on asthma and triggers and social support are necessary even in rural healthcare settings without a large minority population.