Analysis of insect-sting study.
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Anaphylaxis↗
Biomedical subjects
R Y Lin
Publications and source records attributed to R Y Lin.
Exogenous transforming growth factor-beta amplifies its own expression and induces scar formation in a model of human fetal skin repair.
OBJECTIVE: Fetal skin wounds heal without scarring. To determine the role of TGF-beta 1 in fetal wound healing, mRNA expression of TGF-beta 1 was analyzed in human fetal and adult skin wounds. METHODS: Human fetal skin transplanted to a subcutaneous location on an adult athymic mouse that was subsequently wounded heals without scar, whereas human adult skin heals with scar formation in that location. In situ hybridization for TGF-beta 1 mRNA expression and species-specific immunohistochemistry for fibroblasts, macrophages, and neutrophils were performed in human adult wounds, fetal wounds, and fetal wounds treated with a TGF-beta 1 slow release disk. RESULTS: Transforming growth factor-beta 1 mRNA expression was induced by wounding adult skin. No TGF-beta 1 mRNA upregulation was detected in human fetal skin after wounding. However, when exogenous TGF-beta 1 was added to human fetal skin, induction of TGF-beta 1 mRNA expression in human fetal fibroblasts occurred, an adult-like inflammatory response was detected, and the skin healed with scar formation. CONCLUSIONS: Transforming growth factor-beta 1 is an important modulator in scar formation. Anti-TGF-beta 1 strategies may promote scarless healing in adult wounds.
Adult↗
Microvascular function and rheologic changes in hyperdynamic sepsis.
OBJECTIVE: To investigate the rheologic changes and circulatory abnormalities at the microvascular level during severe sepsis. DESIGN: Prospective, controlled trial. SETTING: Medical and surgical intensive care units of a university-affiliated hospital. PATIENTS: Nine normal controls and eight adult patients with severe sepsis who met the study entrance criteria. INTERVENTIONS: Forearm blood flow was measured at rest and during reactive hyperemia by air plethysmography. Simultaneous hemodynamic measurements and blood samples for rheologic measurements were taken. MEASUREMENTS AND MAIN RESULTS: Red blood cell deformability index was determined using a simple filtration procedure. Leukocyte aggregation in whole human blood was detected by using a leukergy test. Expression of the neutrophil adhesion molecule CD11b/CD18 was measured using a monoclonal antibody and flow cytometry. All data were taken within 24 hrs of the patient meeting criteria for entrance into the study. Cardiac output, oxygen delivery, and oxygen consumption measurements were consistent with the hyperdynamic phase of severe sepsis. Forearm blood flow was significantly (p < .05) greater in septic patients (21 +/- 3 mL/min) than in controls (12 +/- 2 to 36 +/- 5 mL/min (p < .05), while in the septic patients, forearm blood flow during reactive hyperemia increased from 21 +/- 3 to 32 +/- 4 mL/min. The ratio of forearm blood flow during reactive hyperemia to forearm blood flow at rest was 3.2 +/- 0.1 in the controls and 1.6 +/- 0.1 in the septic patients (p < .01). The red blood cell deformability index in whole blood was significantly (p < .01) decreased in the septic patients compared with the control subjects (0.41 +/- 0.07 vs. 0.98 +/- 0.08 mL/min). This difference remained true when the hematocrit was adjusted to 45% (0.82 +/- 0.06 vs. 1.04 +/- 0.06 mL/min; p < .05). Increased expression of the neutrophil adhesion molecule CD11b/CD18 was observed in septic patients (349 +/- 46 logarithmic fluorescence units) as compared with control subjects (233 +/- 26 logarithmic fluorescence units; p < .05). Leukergy was also significantly (p < .05) increased in septic patients (17.7 +/- 3.8%) as compared with control subjects (8.9 +/- 1.6%). A significant correlation was observed between leukergy and the expression of the neutrophil adhesion molecule CD11b/CD18 in controls and septic patients (r2 = .62; p < .01). Leukergy was also inversely correlated with whole blood red blood cell deformability index (r2 = .28; p < .05). CONCLUSIONS: Reactive hyperemia in the forearm is significantly diminished in patients with sepsis, suggesting impaired microvascular blood flow. Rheologic changes, including impaired red blood cell deformability, increased leukocyte aggregation, and endothelial adherence, may contribute to this abnormality by compromising effective capillary cross-sectional area.
Adult↗
The fetal fibroblast: the effector cell of scarless fetal skin repair.
Human fetal skin heals without scar formation when it is transplanted to a subcutaneous location on an adult athymic mouse and subsequently wounded. In contrast, human fetal skin of identical gestational age heals with scar formation when transplanted to a cutaneous location on the athymic mouse recipient. To determine if mouse (adult) or human (fetal) fibroblasts are healing the graft wounds, we performed indirect immunohistochemistry for mouse and human collagen types I and III. Full-thickness skin grafts (n = 51) from human fetuses at 18 weeks' (n = 4) or 24 weeks' (n = 2) gestational age were placed onto athymic mice in two locations: cutaneously onto a fascial bed and subcutaneously in a pocket under the murine panniculus carnosus. Linear incisions were made in each graft 7 days after transplantation. Grafts were harvested at 7, 14, and 21 days after wounding and stained with hematoxylin and eosin or Mallory's trichrome. Immunohistochemistry for either human collagen type I or type III or for mouse collagen type I was performed. The subcutaneous grafts healed with human collagen types I and III in a scarless pattern. The wound collagen pattern was reticular and unrecognizable from the surrounding dermis. Hair follicles and sebaceous gland patterns were unchanged in the wounded dermis. Conversely, the cutaneous grafts healed with mouse collagen in a scar pattern with disorganized collagen fibers and no appendages. Mouse collagen scar was present along the base of the cutaneous grafts and as a thin capsule around the subcutaneous grafts. We conclude that (1) subcutaneous grafts heal with human fetal collagen and no scar formation, and (2) cutaneous grafts heal with mouse collagen in a scar pattern. Fetal fibroblasts can heal fetal skin wounds without scar despite being perfused by adult serum and inflammatory cells in an adult environment. These data suggest that the fetal fibroblast is the major effector cell for scarless fetal skin repair.
Animals↗
Hypocomplementaemic urticarial vasculitis, interstitial lung disease and hepatitis C.
A 42-year-old man developed persistent urticaria and angio-oedema responsive to systemic steroids. A skin biopsy revealed leucocytoclastic vasculitis. C4 levels were consistently decreased in the setting of a mildly elevated erythrocyte sedimentation rate. Pulmonary function studies revealed a restrictive pattern, and there was eosinophilia in bronchial lavage fluid. Antibody to hepatitis C virus was positive, and there was mild elevation of serum aminotransferase. We believe that this case represents another possible manifestation of immunological disease associated with hepatitis C virus infection.
Adult↗
[Arytenoid subluxation following endotracheal intubation--a case report].
A previously healthy 39-yr-old man was scheduled for exploratory laparotomy due to acute abdomen. There was no sign of difficult intubation. After induction of anesthesia with thiopental and succinylcholine, the trachea was easily intubated with a 7.0 mm cuffed endotracheal tube. Surgery for a ruptured appendix with 2 drainage tubes lasted for 75 min was uneventful. At the end of surgery, the endotracheal tube was removed without difficulty. On the 1st postoperative day, the patient developed stridor. The symptom persisted even after conservative treatment and removal of NG tube. On the 12th postoperative day, a telescopic videolarygoscopy revealed immobile right vocal cord with anterior and medial displacement to the right. Arytenoid cartilage was moderately edematous. A diagnosis of right arytenoid subluxation was then made. On the 17th postoperative day, a closed reduction of right arytenoid cartilage using direct laryngoscope was performed successively under general anesthesia. Eight weeks after the reduction, his voice and laryngoscopic findings were normal. There has been only 18 reports with 27 cases of this complication found in the literature. However, it is generally believed that it is not so unusual. The post-intubation syndromes, such as sore throat, dysphonia, odynophagia, difficulty in swallowing or breathing which persists beyond 5 days warrant ENT consultation. Abnormal mobility of vocal cord, edema over arytenoid area found by indirect laryngoscopy should suggest the complication. Further confirmation is then needed. Although the result of our case is good, the reduction should ideally be done within 24-48 h after the incidence to avoid unfavorable long-term sequelae.
Adult↗
Asthma and related atopic disorders in outpatients attending an urban HIV clinic.
BACKGROUND: Drug hypersensitivity and pruritic cutaneous disorders are common in human immunodeficiency virus (HIV)-infected patients. Systematic cross-sectional studies, detailing the pattern of atopic disease, however, have not been performed in patients with HIV infection. OBJECTIVE: To analyze the relationships between atopic disease and factors relating to lifestyle, environment, gender, genetics, and HIV disease-associated immune cell depletion. METHODS: CD4 cell counts and interview data were recorded in a survey of 136 adult patients attending a community hospital-based HIV outpatient clinic. The reported presence of various atopic and related conditions (including asthma, hay fever, otitis, sinusitis, and dermatitis) were analyzed for prevalence and associations with CD4 cell depletion, family atopy, and other factors using logistic regression. RESULTS: Seventeen percent and 15% of patients claimed to have asthma and hay fever, respectively. Eleven percent claimed chronic nasal symptoms without known hay fever. A recent CD4 count > or = 200 cells/dL was significantly associated with current asthma (P = .01) and this association remained after adjusting for other significant factors. The mean recent log CD4 count for patients with current asthma was significantly higher than other patients (5.63 +/- .73 versus 4.92 +/- 1.38, P = .001). There was no association between rhinitis and CD4 cell depletion. Histories of recent sinusitis (24%) and ear infections (16%) were common, and were significantly associated with current hay fever +/- chronic nasal symptoms (P < .05). Chronic pruritic rashes or eczema were reported in 29% and were more frequent in those with CD4 counts < 200/dL. Family histories of either asthma or hay fever were significantly associated with several condition including hay fever +/- chronic nasal symptoms, otitis, drug allergy, chronic pruritic rashes or eczema, and asthma. CONCLUSIONS: Although atopic disorders in the setting of HIV infection appear to have some clinical associations similar to that reported for the general population, asthma appears to have a predilection towards less severe CD4 cell depletion. The potential role of chronic rhinitis +/- family atopy as risk factors for sinusitis and otitis may be important because treatment of selected individuals with rhinitis may potentially decrease some paranasal disease-related morbidity in HIV infection.
Adolescent↗
Clinical characteristics of adult asthmatics requiring intubation.
Fifty eight admissions for 52 adult asthmatics who required intubation were reviewed for the years of 1988-1995 to examine factors related to specific clinical patterns and profile the course of these patients. Of the 56 admissions where patients were intubated for respiratory failure and/or cyanosis, 5 were associated with significant complications of mechanical ventilation/intubation (pneumothorax, subcutaneous emphysema, aspiration pneumonia, and laryngeal edema) and there were no fatalities. Patients > or = 35 years of age had significantly more profound respiratory acidosis in initial arterial blood gases (pH = 7.14 versus 7.23, p = 0.03). In contrast, patients with a history of drug abuse or psychiatric disorders had lower mean pCO2 (p < = 0.01). The overall mean length of intubation was 17.6 hours, while the overall mean hospital stay was 6.6 days. Longer intubation times were associated with the occurrence of major complications, female gender, and hospital administration of ipratropium. Hospital stay was correlated with length of intubation, later month of admission, and earlier year of admission. Common precipitating factors noted for first admissions were upper respiratory infections (61%), followed by allergy or smoke exposure (13%), compliance related problems (12%), and drug abuse/inhalation (6%). Inhaled anti-inflammatory drugs, oral steroids or either were taken at the time of admission by 35%, 35% and 65% of the patients, respectively. There was an even distribution of patients with respect to medical insurance coverage type, admissions per season or year, ethnicity, marital status, and gender. We conclude that severe asthma resulting in respiratory failure is common despite the frequent use of anti-inflammatory asthma medications. Mechanical ventilatory support can be administered safely in the majority of these patients and should be considered early in acute asthma.
Adult↗
Diagnostic and prognostic role of basic fibroblast growth factor in Wilms' tumor patients.
Basic fibroblast growth factor (bFGF) is a potent angiogenic peptide implicated in the growth and metastasis of solid tumors. Elevated concentrations of bFGF have been found in the urine of patients with bladder, prostate, and renal tumors. Furthermore, urinary bFGF levels have been shown to correlate with extent of disease. In order to test the utility of urinary bFGF as a Wilms' tumor marker, we measured bFGF levels in preoperative and postoperative urine samples from 97 patients with Wilms' tumor. Preoperative urine samples (n = 97), early postoperative samples obtained from 1 to 3 weeks after surgery (n = 43), and late postoperative samples obtained from 1 to 6 months after surgery (n = 66) were collected from Wilms' tumor patients at 30 institutions between 1989 and 1993. Urine samples from age-matched controls (n = 17) were also obtained. The bFGF levels were determined in duplicate by a competitive sandwich ELISA capable of measuring bFGF at the pg/ml level. Samples were normalized for creatinine content. Urinary bFGF was elevated in 42% of preoperative samples when compared to controls (>90th percentile of normal). Patients with stage III, IV, and V disease had significantly higher preoperative levels of urinary bFGF when compared to patients with stage I and II disease (P < 0.01). Patients with relapse or persistent disease had significantly elevated late postoperative bFGF levels when compared to disease-free patients and controls (P < 0.05). Thus, in patients with Wilms' tumor, elevated preoperative urinary bFGF levels raise the suspicion of aggressive disease while elevated postoperative levels may indicate recurrence or persistence of disease. These data suggest that bFGF is a biological marker for Wilms' tumor and may have a role in the evaluation of patients with this disease.
Biomarkers, Tumor↗
Scarless human fetal skin repair is intrinsic to the fetal fibroblast and occurs in the absence of an inflammatory response.
The fetus heals skin wounds without scar formation. Human fetal skin that is transplanted to a subcutaneous location on an adult athymic mouse and subsequently wounded heals without scar formation, whereas the same skin heals with scar formation when transplanted to a cutaneous location. In situ hybridization with species-specific DNA probes and immunohistochemistry were performed to characterize the healing process of human fetal skin in these two locations. Species-specific human and mouse DNA probes were constructed and used to probe graft wounds under high stringency in situ hybridization conditions. Immunostaining for species-specific fibroblasts, macrophages, and neutrophils was also performed. We found that the cutaneous human fetal grafts healed with scar and showed an influx of mouse fibroblasts and macrophages. In contrast, subcutaneous human fetal grafts showed exclusively human fetal fibroblasts in the wound environment, an absence of inflammatory cells, and scar-free repair. We conclude that the highly organized collagen deposition in scarless human fetal wound repair appears to be intrinsic to the human fetal fibroblasts and occurs in the absence of an adult-like inflammatory response.
Journal Article↗
Association between reported use of inhaled triamcinolone and differential short-term responses to aerosolized albuterol in asthmatics in an emergency department setting.
Forty-four adult patients with acute asthma were treated with albuterol at a rate of 15 mg/h over 2 h. Analysis of covariance showed a significantly higher baseline adjusted mean for both percent predicted forced expiratory volume in 1 s (PFEV1) (p = 0.045) and percent predicted forced vital capacity (PFVC) (p = 0.022) at 50 and 110 min for the patients who reported triamcinolone use. Although heart rates decreased overall during the first hour of albuterol treatment, a rise in mean heart rate occurred during the second hour of treatment only in patients reporting triamcinolone use (p = 0.005). After accounting for the effects of parenteral corticosteroids, the effect of reported triamcinolone use remained significant. These data suggest that use of inhaled corticosteroids in this context may be associated with enhanced local and systemic beta-responsiveness, and if a causal relationship could be confirmed, this may constitute yet another advantage of early inhaled corticosteroid treatment in asthma. These data also suggest that chronotropic effects of high-dose albuterol should be monitored in patients using inhaled triamcinolone.
Acute Disease↗
Relationships between plasma cytokine concentrations and leukocyte functional antigen expression in patients with sepsis.
OBJECTIVE: To determine the relationships between cytokine concentrations and alterations in leukocyte functional antigen expression in sepsis. DESIGN: Prospective, cross-sectional study. SETTING: Respiratory, coronary, and medical intensive care units in a university hospital. PATIENTS: Forty subjects consisting of: a) patients with severe sepsis, b) patients with sepsis, c) critically ill nonseptic patients, and d) normal controls. INTERVENTIONS: None. MEASUREMENTS: Plasma concentrations of interleukin (IL)-1 beta, IL-6, IL-8, IL-10, interleukin-1 receptor antagonist (IL-1Ra), and tumor necrosis factor (TNF)-alpha were determined by enzyme-linked immunosorbent assay (ELISA). Peripheral blood monocyte HLA-DR and CD14 expression and neutrophil CD11b expression were determined by flow cytometry. Measurements were taken within 24 hrs of admission to the intensive care unit and/or clinical presentation. MAIN RESULTS: Significantly increased plasma IL-6, IL-8, IL-10, and TNF-alpha concentrations were observed in the severe sepsis group compared to normal controls. Increases in IL-1Ra were not significant. Monocyte HLA-DR expression, significantly decreased in patients with severe sepsis, was correlated both with IL-6 (p < .005) and IL-8 concentrations (p < .001). Both of these cytokines had close correlations to Acute Physiology and Chronic Health Evaluation (APACHE) II scores which were also correlated with monocyte HLA-DR. Neutrophil CD11b, which was increased in all infected patients, was significantly correlated with the ratio between IL-1 and IL-1Ra concentrations (p < .001). The percent of CD14+ monocytes was lowest in patients with severe sepsis and showed a significant covariate effect from IL-8 concentrations (p < .001). CONCLUSION: These findings suggest that the expression of specific functional molecules on peripheral blood leukocytes is variably related to the net production of certain monokines in sepsis.
APACHE↗
Alterations in C3, C4, factor B, and related metabolites in septic shock.
Forty subjects consisting of (i) patients with septic shock, (ii) patients with sepsis without shock, (iii) critically ill non-septic patients, and (iv) normal controls were studied for plasma C3, C4, factor B, iC3b, C4d, Bb, and SC5b-9 levels in an attempt to profile the pattern of complement activation in sepsis. Significant decreases in plasma C3 and C4 concentrations were observed in septic shock patients compared to normal as well as to critically ill subjects. When adjusted for illness severity, levels of C3 but not C4 showed significant differences between septic shock and critically ill patients. Concentrations of the complement metabolite Bb as well as the Bb to factor B ratio were significantly increased in septic shock patients. SC5b-9 levels were significantly higher in septic shock patients compared to normal as well as to critically ill subjects. No increases in C4d or iC3b were observed, but the iC3b to C3 ratio was higher in septic shock patients compared to that in normal subjects. In septic shock patients, there were significant correlations between SC5b-9 and Bb (P = 0.0213) concentrations and between C3 and Factor B concentrations (P = 0.0041). SC5b-9 levels also were correlated with lactate levels in septic shock patients (P = 0.0091). These findings demonstrate a metabolite pattern consistent with primarily alternative and terminal pathway activation in septic shock patients. Decreases in C4, a classical pathway component, may not be specific for septic shock and do not appear to be necessarily due to significant complement consumption/activation.
Adult↗
Identification and characterization of a 30 kd major allergen from Parapenaeus fissurus.
The allergenic components of the shrimp (Parapenaeus fissurus) were identified by immunoblotting with sera from 10 allergic patients. Six components, ranging in molecular weight from about 86 to 39 kd, showed IgE-binding activity and were identified as allergens of the shrimp. The component with a molecular weight of about 39 kd showed the highest frequency of IgE binding (70%) and was considered to be one of its major allergens. Two monoclonal antibodies against this 39 kd component were generated, and their antigenic cross-reactivity with five different kinds of seafood, shrimp, crab, cuttlefish, oyster, and pomfret was analyzed. Monoclonal antibody 1-6-10B reacted with the 39 kd component from shrimp only, but monoclonal antibody 2-7-1E also reacted with the 39 kd component from crab. By extraction with 0.5% sodium dodecylsulfate and ethanol precipitation, a highly purified shrimp 39 kd component was obtained. In two-dimensional gel electrophoresis six isoforms of this purified 39 kd component, with isoelectric point values from 5.1 to 5.6, were identified. No marked difference was observed when the amino acid composition of this purified 39 kd allergen was compared with those of serum albumin from different animals. They all contain a high proportion of acidic amino acids. There was also a 62% to 83% sequence homology among three different pairs of peptide fragments of purified 39 kd components of shrimp and crab. In conclusion, a 39 kd major allergen from the shrimp has been identified and characterized in the present study. According to the suggestions of the International Union of Immunological Societies, this allergen is designated as Par f I.
Allergens↗
Continuous versus intermittent albuterol nebulization in the treatment of acute asthma.
STUDY OBJECTIVES: To compare bronchodilation, chronotropic effects, and side effects of the same dose of nebulized albuterol when given by either intermittent or continuous administration. DESIGN: A randomized assignment of patients to one of the two methods of albuterol nebulization. SETTING: Adult emergency department in an urban public hospital. TYPE OF PARTICIPANTS: Adult patients with acute exacerbations of asthma. INTERVENTIONS: Administration of 30 mg albuterol given over 110 minutes by either continuous or intermittent aerosolization. MEASUREMENTS: FEV1, forced vital capacity, heart rate, and systolic and diastolic blood pressures were measured immediately before treatment and then hourly for two hours. Side effects, symptoms, subsequent admission, and discharge also were noted. MAIN RESULTS: An overall significant decrease in heart rate was observed, indicating the lack of significant chronotropic effects with this dose of albuterol. Both treatments resulted in significant spirometric improvement without a significant treatment difference for the entire group. A difference, however, was found in the relative rates of FEV1 improvement with the two treatments depending on whether patients had an initial FEV1 less than or more than 50% predicted (P = .05). A secondary analysis on patients with an initial FEV1 less than percent predicted demonstrated a higher rate of percent predicted FEV1 increase with the continuously nebulized albuterol group (P = .03). CONCLUSION: This study demonstrates that albuterol can be given safely at this dose by either intermittent or continuous nebulization. Future studies should examine whether continuous nebulization has a reproducible advantage over intermittent nebulization in patients with more severe obstruction.
Acute Disease↗
The role of oral candidiasis in survival and hospitalization patterns: analysis of an inner city hospital human immunodeficiency virus/acquired immune deficiency syndrome registry.
To assess the effect of oral candidiasis (OC) associated with human immunodeficiency virus (HIV) at initial hospital admission on both survival and hospital use, a retrospective analysis was performed in 1,172 hospitalized patients identified by an HIV surveillance program at an inner city public hospital in East Harlem, New York. Survival times were compared using three different HIV staging schemes placing patients with OC into either a common stage with adenopathy patients (Scheme IHS-URV), a common stage with acquired immune deficiency syndrome patients (AIDS; Scheme WRCDC), or an intermediate stage between AIDS patients and all others (Scheme ORAL). Patients without AIDS demonstrated a significantly increased risk of dying (relative risk, 2.61; 95% confidence interval [CI], 1.69, 4.03) if they were initially admitted with OC. Survival times for different stages of disease showed the best between-stage distinction for a Scheme ORAL, with the OC stage having a median survival of 643 days. Mean days of hospitalization also showed best distinctions for Scheme ORAL. Other staging schemes did not distinguish patients as well in terms of both survival times or mean hospitalization days. HIV-infected patients admitted with OC but without AIDS had a discrete survival prognosis and hospitalization course. Therefore, presence of OC even without other immunologic data has implications for institutional resource allocation and planning. These data support, in this context, a separate clinical designation for OC patients.
AIDS-Related Opportunistic Infections↗
Cold urticaria and HIV infection.
Three patients, all seropositive for HIV antibody, complained of swelling and pruritus on the head and limbs when exposed to the cold. All three had received zidovudine for significant CD4 cell depletion, but had no AIDS-defining illnesses. An ice-cube test was positive on each individual. There was no evidence of cold agglutinins, cryoglobulins, syphilis, or other concurrent diseases in any of the patients. This association may represent yet another allergic manifestation in HIV infection.
Adult↗
High serum albuterol levels and tachycardia in adult asthmatics treated with high-dose continuously aerosolized albuterol.
To study the feasibility of using high-dose continuously aerosolized albuterol aerosol in adults, seven adult asthmatic patients were treated eight times with 0.4 mg/kg/h albuterol delivered by continuous nebulization over 4 h. One patient withdrew at 3 h after supraventricular tachycardia developed. This subsided promptly on discontinuing albuterol therapy. Heart rate increases were observed in six of eight treatments and serum albuterol levels at the end of treatment were greater than 25.0 ng/ml in all but one treatment. A mean increase in heart rate of 16.3 percent was observed for the entire group. Of the treatments with elevated (> 25.0 ng/ml) serum albuterol levels, a significant cumulative increase in heart rate was observed with time. A significant improvement of FEV1 was observed (p = 0.0025) with a net increase of 36.8 percent. These data suggest that high-dose continuously aerosolized albuterol treatment in some adult asthmatics can result in markedly elevated serum albuterol levels and potential cardiac stimulation despite spirometric improvement.
Adult↗