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Biomedical subjects

Jay M Portnoy

Publications and source records attributed to Jay M Portnoy.

At least 19 recordsLinked to original sources
PubMed2006

Evidence-based allergy diagnostic tests.

Effective management of allergic diseases relies on the ability to make an accurate diagnosis. Although clinicians rely on experience obtained over many years of practice, such experience is anecdotal and unique to the individual using it. The result is a tendency for patients with similar clinical presentations to receive different diagnoses and treatment, depending on which provider they happened to see. The probability that a patient has a particular diagnosis can be determined using a combination of diagnostic tests. To make the best use of tests, it is important to understand their performance characteristics in terms of reproducibility and likelihood ratios. A test that is reproducible but that does not predict the presence of a disease is not helpful, nor is an accurate test that is not reproducible. To improve the reproducibility of diagnostic tests, it is important that proficiency testing be instituted for both skin and in vitro tests so that the coefficient of variance can be determined. This has already been done for the latter and needs to be done for skin tests as well. With use of a combination of history and appropriate diagnostic tests, the probability that a particular diagnosis is present can be increased or decreased sufficiently either to confirm it or to rule it out. As proficiency testing of allergy tests becomes more common and the use of tests becomes more consistent, we believe that patients with allergic diseases will benefit.

Diagnosis, Differential↗
PubMed2006

The medical effects of mold exposure.

Exposure to molds can cause human disease through several well-defined mechanisms. In addition, many new mold-related illnesses have been hypothesized in recent years that remain largely or completely unproved. Concerns about mold exposure and its effects are so common that all health care providers, particularly allergists and immunologists, are frequently faced with issues regarding these real and asserted mold-related illnesses. The purpose of this position paper is to provide a state-of-the-art review of the role that molds are known to play in human disease, including asthma, allergic rhinitis, allergic bronchopulmonary aspergillosis, sinusitis, and hypersensitivity pneumonitis. In addition, other purported mold-related illnesses and the data that currently exist to support them are carefully reviewed, as are the currently available approaches for the evaluation of both patients and the environment.

Air Pollution, Indoor↗
PubMed2006

Utilization patterns in an asthma intervention.

BACKGROUND: The National Cooperative Inner-City Asthma Study (NCICAS) tested a model of asthma management in which a master's degree-prepared social worker functioned as an asthma counselor. The NCICAS resulted in decreased symptom days and a trend toward fewer emergency department (ED) visits and hospital admissions in the intervention group compared with the control group. OBJECTIVE: To determine whether a real-world implementation would give similar results to the NCICAS. METHODS: Children with moderate or severe persistent asthma were enrolled in a 1-year program, the Inner-City Asthma Intervention (ICAI) program, modeled on the NCICAS. Since the program initially was not designed to be research, data were collected retrospectively. ED and hospital visits were compared 1 year before and after the intervention at 2 of the intervention sites, Children's Mercy Hospital (CMH) and Baystate Medical Center, to determine whether there was a significant change. RESULTS: Data for 93 children from CMH and 77 from Baystate were evaluated. At CMH annual ED visits were 0.38 before, 0.42 during, and 0.41 after the intervention, whereas at Baystate ED visits were 0.09 before, 0.17 during, and 0.15 after the intervention. Mean hospitalizations at CMH increased from 0.06 before to 0.22 during and then decreased to 0.12 after (P > .05), whereas admissions at Baystate increased from 0.03 before to 0.05 during and 0.04 after the intervention. CONCLUSIONS: Asthma self-management interventions can lead to decreases in asthma utilization under controlled circumstances. Further prospective studies are needed to determinewhether the ICAI intervention is effective under real-world conditions.

Allergens↗
PubMed2006

Diagnosing asthma in young children.

PURPOSE OF REVIEW: Asthma is defined by the 1997 National Asthma Education and Prevention Program guideline as a chronic inflammatory disorder of the airways which leads to an increase in bronchial hyperresponsiveness to a variety of stimuli or triggers. Since it is difficult to determine whether an individual patient has the above pathophysiology, particularly in young children, it is essential that clinically useful criteria be identified that can serve as proxies for the presence of asthma. RECENT FINDINGS: There are three reasons for making a diagnosis: to identify the most effective treatment to alleviate symptoms and prevent mortality; to educate the parent or primary caregiver to manage symptoms and avoid triggers; and to estimate the prognosis. A diagnostic test is a procedure which gives a rapid, convenient and inexpensive indication of whether a patient has a certain disease. The likelihood ratio incorporates both the sensitivity and specificity of the test and provides a direct estimate of how much a test result will change the odds of having a disease. SUMMARY: By applying the principles of evidence-based medicine to define likelihood ratios for each criterion, it should be possible to define the probability of asthma and to identify the best treatment. Future research should permit accurate correlations to be drawn between the underlying pathophysiology and the clinical condition commonly known as asthma.

Asthma↗
PubMed2006

Adherence in young children with asthma.

PURPOSE OF REVIEW: To discuss the unique challenges of managing asthma in young children and to review the literature over the past year with regard to regimen adherence in this relatively understudied population. RECENT FINDINGS: Young children and their families face unique challenges in dealing with asthma and these have the potential to affect regimen adherence. They include the time and effort required by asthma-management activities (e.g. nebulizer use), dependency on parents for asthma care, and the limited ability of children to communicate about their symptoms. Five published studies were found for the past year. They covered three areas: adherence assessment (e.g. electronic monitoring versus diary cards), device impact on adherence (e.g. influence of the novelty of medication-delivery device), and adherence interventions (e.g. parental education regarding symptoms). SUMMARY: Research suggests that several components need to be considered when designing interventions to improve adherence for young children with asthma: to consider the strain in the caregiver role when developing the treatment regimen, to provide devices that parents and children can use, to monitor adherence with electronic monitoring, and to address parents' concerns and perceptions about treating prodromal symptoms of an asthma exacerbation. Because many parents are hesitant to treat cough symptoms, an additional training component may need to be added to address this concern.

Age Factors↗
PubMed2005

Health effects of indoor fungi.

OBJECTIVE: To review the nontoxic harmful effects that poor indoor air quality caused by fungi can have on health. DATA SOURCES: We searched PubMed for publications related to the various topics discussed in this review, and we relied on our knowledge of the field. STUDY SELECTION: Where more than one publication was relevant, we attempted to identify a consensus of the reports and cited the most relevant articles. Priority was given to randomized controlled trials and expert reports when available, although much of the information herein relates to laboratory research. RESULTS: Actively growing fungal colonies can release volatile substances that have an unpleasant smell, leading to psychological responses in the occupants such as fatigue and nausea. Symptoms that are likely caused by indoor fungi include respiratory complaints that involve the nose and lungs, eye symptoms, and mucous membrane irritation. These adverse effects can occur by a variety of mechanisms, including IgE-mediated hypersensitivity, fungal infection, irritant reaction to spores or fungal metabolites, and possibly toxic reaction to mycotoxins. CONCLUSIONS: Reduced fungal exposure can reasonably be expected to improve health. Removal of moisture from the indoors and proper maintenance of air filters can aid in prevention and elimination of fungi from the home environment. Small areas of present contamination can be cleaned with a dilute bleach solution, which kills viable colonies and removes their mycelia. If fungal contamination is not addressed early, substantial damage can occur, requiring professional remediation. Above all, the individual should not panic at the first sight of fungi growing in the home. Regular inspection and cleaning can prevent many fungus-related problems.

Air Pollution, Indoor↗
PubMed2005

Sampling for indoor fungi: what the clinician needs to know.

PURPOSE OF REVIEW: A great deal of concern has arisen recently regarding the potential adverse effects of indoor fungi. Our understanding of this complex problem has been hampered by a lack of standardized protocols for performing an indoor assessment for fungi. Without such standards, it is difficult to compare results from one study with those from another or to measure the effect of indoor fungal contamination on a building and its occupants. RECENT FINDINGS: References were identified that were relevant to indoor fungal sampling, health effects or remediation by searching Pubmed using the keywords 'indoor fungi.' Fungi cause three primary adverse effects: (a) they can damage a building, (b) they can render a building unpleasant to live in by looking and smelling bad, and (c) they might cause adverse health effects in sensitive individuals. Sampling methods used to evaluate indoor environments include air sampling for spores, measurement of allergens in house dust, and determination of microbially generated volatile organic compounds, ergosterols, glucans, and mycotoxins, as well as environmental conditions that lead to fungal contamination. SUMMARY: Prevention of fungal contamination involves removal of moisture sources and humidity and early identification. If fungi are found on indoor surfaces, they can be removed using a dilute bleach/detergent solution that both kills the microorganisms and denatures allergens and toxins. Larger areas require professional remediation.

Air↗
PubMed2004

Pediatric asthma: a look at adherence from the patient and family perspective.

Although extensive research has been done in an effort to understand and promote adherence in pediatric asthma, little progress has been made in reducing the prevalence of nonadherence. Some researchers argue that a paradigm shift is necessary to advance the adherence field. Despite the recent trend for increasing the role of families in determining treatment plans, a patient-centered approach has been lacking in adherence to a daily regimen. It is clear that, although patients and families show evidence of inadvertent nonadherence (eg, forgetfulness), they also engage in volitional or intentional nonadherence, via reasoned and purposeful decisions. Patients conduct "experiments" with their regimen components in an effort to balance the burden of disease with the burden of treatment. These experiments typically involve some degree of nonadherence. Perhaps, if researchers strive to better understand the decision-making process involved in these experiments, health care providers can guide families in making adherence decisions that would lead to attainment of treatment goals, improvement in quality of life, and realization of positive clinical outcomes.

Adult↗
PubMed2004

Evidence-based strategies for treatment of allergic rhinitis.

In this review, an evidence-based medicine approach to diagnosis and treatment for allergic rhinitis is reviewed. We performed a search of the medical literature for randomized, placebo-controlled trials of nonsedating antihistamines, intranasal corticosteroids, montelukast, azelastine, allergen immunotherapy, and anti-IgE. The mean numbers needed to treat were: nonsedating antihistamines--15.2; nasal corticosteroids--4.4; montelukast--14.3; azelastine--5.0; allergen immunotherapy--4.6; and anti-IgE--12.4. Treatment thresholds for use were: antihistamines--23%; nasal corticosteroids--8%; azelastine--16%; montelukast--8%; anti-IgE--50%; and immunotherapy--25%. When used appropriately, this information could become very useful for clinicians, particularly if cost, convenience, and other indirect factors can be included.

Adrenal Cortex Hormones↗
PubMed2004

Sampling for indoor fungi.

BACKGROUND: A great deal of concern has arisen recently regarding the potential adverse effects of indoor fungi. Our understanding of this complex problem has been hampered by a lack of standardized protocols for performing an indoor assessment for fungi. Without such standards, it is difficult to compare results from one study with those from another or to measure the effect of indoor fungal contamination on a building and its occupants. METHODS: We reviewed the medical literature and here describe a hypothesis-driven approach to planning, sampling, and interpreting the results of indoor assessments for fungi. RESULTS: Fungi cause 3 primary adverse effects: (1) they can damage a building, (2) they can render a building unpleasant to live in by looking and smelling bad, and (3) they might cause adverse health effects in sensitive individuals. Sampling methods used to test hypotheses include air sampling for spores, measurement of allergens in house dust, and determination of microbially generated volatile organic compounds, ergosterols, glucans, and mycotoxins, as well as environmental conditions that lead to fungal contamination. CONCLUSIONS: Standardized approaches for performing and reporting assessments of indoor fungi are essential if our understanding of this complex field is to improve.

Air Microbiology↗
PubMed2004

Allergen immunotherapy in the prevention of asthma.

PURPOSE OF REVIEW: Asthma is a disease causing significant morbidity and mortality. In the recent past, there has been an explosion of pharmacotherapeutic options attempting to control the disease. Unfortunately, none of the current options offers the promise of prevention or a permanent cure. However, there appear to be exciting, new data emerging to support the hypothesis that the prevention or early treatment of allergic rhinitis, such as with the use of allergen immunotherapy, may help mitigate the severity of bronchial symptoms and even prevent the development of asthma. In this paper, we review recent research published proposing immunotherapy as a means of preventing the development of, or at least ameliorating, allergic asthma. RECENT FINDINGS: There is evidence that the upper and lower airways may be considered a single unit, with the nasal and bronchial mucosa having features in common. Epidemiological, pathophysiological and clinical studies have shown that they can be affected by similar inflammatory triggers, with interconnected mechanisms amplifying the inflammatory cascade. Allergic rhinitis is interrelated to, and is a risk factor for, the development of asthma. An evidence-based review validates the successful use of allergen immunotherapy in treating allergic rhinitis and asthma. There is promising evidence advocating its use in the prevention of clinical asthma. SUMMARY: This article explores current research pertaining to the use of immunomodulation, such as by using allergen immunotherapy, to ameliorate and prevent the development of allergic asthma.

Allergens↗
PubMed2004

Review of cetirizine hydrochloride for the treatment of allergic disorders.

Cetirizine hydrochloride is an orally-active and selective histamine (H(1))-receptor antagonist. It is a second-generation antihistamine and a human metabolite of hydroxyzine. Therefore, its principal effects are mediated via selective inhibition of peripheral H(1) receptors. The antihistaminic activity of cetirizine has been documented in a variety of animal and human models. In vivo and ex vivo animal models have shown negligible anticholinergic and antiserotonergic activity. In clinical studies, however, dry mouth has been seen more commonly with cetirizine than with placebo. In vitro receptor binding studies have shown no measurable affinity for receptors other than H(1) receptors. Auto-radiographical studies with radiolabelled cetirizine in the rat have shown negligible penetration into the brain. Ex vivo experiments in the mouse have shown that systemically administered cetirizine does not significantly occupy cerebral H(1) receptors. Impairment of CNS function is comparable to other low-sedating antihistamines at the recommended dose of 10 mg/day for adults. It has anti-inflammatory properties that may play a role in asthma management. It does not interact with concomitantly administered medications, it has no cardiac adverse effects, and it does not appear to be associated with teratogenicity. Cetirizine is predominantly eliminated by the kidneys with a mean elimination half-life is 8.3 h. It is rapidly absorbed, and significant clinical inhibition of a wheal and flare response occurs in infants, children and adults within 20 min of a single oral dose and persists for 24 h. No tolerance to the wheal and flare response occurs even after 1 month of daily treatment. The clinical efficacy of cetirizine for allergic respiratory diseases has been established in numerous trials. There is evidence that cetirizine improves symptoms of urticaria. Concomitant use of cetirizine also decreases the duration and amount of topical anti-inflammatory preparations needed for the treatment of atopic dermatitis. Interestingly, several clinical studies suggest that cetirizine may be useful in the treatment and prevention of mild asthma.

Anti-Allergic Agents↗
PubMed2003

Modification of provider behavior to achieve improved asthma outcomes.

Despite an abundance of scientific evidence supporting the use of guidelines, adherence to asthma practice guidelines by physicians generally is low, regardless of provider and patient characteristics. As a result, scientific information, obtained with great effort and at huge expense, is not being translated into clinical practice. To remedy this, we developed a disease management program that emphasizes alteration of provider behavior using operant conditioning. We did this by placing asthma educators in private offices for up to 8 weeks. The educators used a combination of problem-based learning, role modeling, and operant conditioning with positive reinforcement to affect behavior change. As a result of these behavior changes, by the end of 8 weeks the cost to treat asthma patients decreased, despite an increase in the cost of medications. We concluded that behavior-oriented programs targeted at provider offices can lead to improved asthma care while reducing costs.

Asthma↗
PubMed2003

Development of an asthma disease management program in a children's hospital.

The incidence, morbidity, and mortality of asthma have been increasing at an alarming rate, making asthma the most common chronic illness of childhood. An asthma disease management program was developed to improve the care and management of patients with asthma--a comprehensive health care delivery model that was designed to improve the management of patients with asthma was designed and implemented. The goal of the program was to provide high-quality interventions for those children diagnosed with asthma. The asthma disease management program at Children's Mercy Hospital improved the care received, decreased costs, and improved the quality of life for those children with asthma.

Asthma↗