Racial Differences in Allergen Sensitivity Christine L.M. Joseph, Edward L. Peterson, Christine C. Johnson and Dennis R. Ownby Chest 2004;126;1004-1005 DOI 10.1378/chest.126.3.1004 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/126/3/1004.full.html
Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright2004by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692
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secondary to lung biopsy in ARDS patients carries major deleterious consequences. In our study, the presence of BPF was not associated with the in-hospital mortality rate (mortality in patients with BPF, 46%; mortality in patients without BPF, 50%). In our experience, BPF rarely has important effects on gas exchange, and, in fact, a substantial quantity of ventilation has been reported3,4 to occur via the chest tube in patients with BPF. While BPF has limited ventilator liberation in the past, the current guidelines recommend continuing spontaneous breathing trials to liberate patients from mechanical ventilation regardless of chest tube status.5 Finally, our experience has been that with the use of lower transpulmonary pressures in the ventilation of ARDS patients, the risk of BPF from lung biopsy has fallen considerably.6,7 Thus, we continue to believe that surgical lung biopsy can be safely performed in selected ARDS patients. Sanjay R. Patel, MD John Wain, MD, FCCP Atul Malhotra, MD, FCCP Harvard Medical School Boston, MA Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail:
[email protected]). Correspondence to: Atul Malhotra, MD, FCCP, Pulmonary and Critical Care, BWH Hospital, 75 Francis St, Boston, MA 02115; e-mail:
[email protected]
References 1 Patel SR, Karmpaliotis D, Ayas NT, et al. The role of open-lung biopsy in ARDS. Chest 2004; 125:197–202 2 Sekine Y, Behnia M, Fujisawa T. Impact of COPD on pulmonary complications and on long-term survival of patients undergoing surgery for NSCLC. Lung Cancer 2002; 37:95–101 3 Bishop MJ, Benson MS, Pierson DJ. Carbon dioxide excretion via bronchopleural fistulas in adult respiratory distress syndrome. Chest 1987; 91:400 – 402 4 Powner DJ, Cline CD, Rodman GH Jr. Effect of chest-tube suction on gas flow through a bronchopleural fistula. Crit Care Med 1985; 13:99 –101 5 Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 1996; 335:1864 –1869 6 The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342:1301–1308 7 Pierson DJ. Management of bronchopleural fistula in the adult respiratory distress syndrome. New Horiz 1993; 1:512– 521
Racial Differences in Allergen Sensitivity To the Editor: We read with interest the article in CHEST by Celedo´ n et al (January 2004)1 on ethnicity and skin test reactivity to aeroallergens. The authors found that African Americans were more likely to have skin test reactions to outdoor allergens. We note that upward of 65% of the nonwhite children in the study of Celedo´ n et al resided in urban areas, compared to 9% of the white children. Readers may be interested in a similar analysis that we conducted2 among 569 middle-class African-American and white
Table 1—Allergen Sensitivity by Race* Serum IgE Levels ⬎ 0.35 Allergen
AA, %
D farinae D pteronyssinus Cat Dog Ragweed Bluegrass Alternaria Cockroach
21.0 16.4 9.5 4.8 23.0 23.0 14.8 0.0
Skin Test Reactive
White, % p Value 13.4 11.6 10.1 5.9 11.8 12.3 13.5 2.6
0.115 0.280 0.884 0.736 0.016 0.023 0.796 0.261
AA, % 9.0 12.8 10.3 7.7 19.0 17.7 18.0 ND
White, % p Value 15.4 16.8 11.7 4.9 14.2 9.5 14.0 ND
0.135 0.372 0.710 0.312 0.264 0.027 0.357
*AA ⫽ African American; ND ⫽ not done.
children residing in a geographically defined suburban area of Detroit, MI. These children, who were between the ages of 6 and 8 years, were invited to undergo a clinical evaluation, including the measurement of specific IgE levels and the performance of skin-prick tests. The skin-prick tests were performed by using commercial extracts of Dermatophagoides farinae, Dermatophagoides pteronyssinus, cat, dog, Alternaria, short ragweed, and bluegrass, in addition to saline solution and histamine solution (1 mg/mL), which acted as positive and negative controls, respectively. A positive skin test result was defined as one with a sum of perpendicular wheal diameters of ⬎ 4 mm with a larger surrounding flare. Allergen-specific serum IgE concentrations were measured using the commercially available assays to the allergens listed above, along with a sample of children who also were tested for cockroach. A specific IgE concentration of ⬎ 0.35 IU/mL was considered to be evidence of a detectable antibody. Our results showed that African-American children were more likely to be allergic to ragweed and bluegrass according to serum IgE concentrations, and to bluegrass according to skin-prick test (Table 1). These were the only statistically significant differences observed by race. Thus, our earlier findings in nonurban children corroborate those of Celedo´ n et al.1 For more information, please see the May 2000 issue of CHEST. Christine L.M. Joseph, PhD, FCCP Edward L. Peterson, PhD Christine C. Johnson, PhD Henry Ford Health System Detroit, MI Dennis R. Ownby, MD Medical College of Georgia Augusta, GA Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail:
[email protected]). Correspondence to: Christine L.M. Joseph, PhD, FCCP, Henry Ford Health System, Department of Biostatistics & Research Epidemiology, 1 Ford Pl, 3E, Detroit, MI 48202; e-mail:
[email protected]
References 1 Celedo´ n JC, Sredl D, Weiss ST, et al. Ethnicity and skin test reactivity to aeroallergens among asthmatic children in Connecticut. Chest 2004; 125:85–92
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Communications to the Editor
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2 Joseph CLM, Ownby DR, Peterson EL, et al. Racial differences in physiologic parameters related to asthma among middle-class children. Chest 2000; 117:1336 –1344
Conventional vs Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration of the Mediastinum
To the Editor: To the Editor: We appreciate the interest of Dr. Joseph and colleagues in our recent article in CHEST (January 2004)1 on ethnicity and skin test reactivity to allergens among children with asthma. We thank them for bringing their article on racial differences in physiologic parameters related to asthma2 to the attention of the readers of CHEST. We would like to point out that the results of our recent study and those of the study conducted by Joseph and colleagues2 are not comparable. Whereas our study included only children with asthma (791 children), their study included children with and without asthma. In the study conducted by Joseph et al, there was no difference in total serum levels of IgE between AfricanAmerican children with asthma (8 children) and EuropeanAmerican children with asthma (49 children). In their study, African-American children without asthma had a higher total serum IgE level than did European-American children without asthma. For the analysis of the relation between sensitization to specific allergens and ethnicity, Joseph et al did not present the results of an analysis that had been stratified by asthma status. Thus, it is not clear whether the reported association between African-American ethnicity and sensitization to two outdoor allergens was present in children with or without asthma. It should also be noted that our analysis of the relation between ethnicity and allergen sensitization among children with asthma was adjusted for health insurance status, area of residence, asthma severity, and other potential confounders. In the study by Joseph et al, the analysis of the relation between ethnicity and allergen sensitization was not adjusted for potential confounders. What the findings of both our study and those of the study conducted by Dr. Joseph and colleagues suggest is that allergy skin testing should be considered more often in African-American children with symptoms that are suggestive of allergic diseases such as asthma. Finally, allergen sensitization in minority populations is deserving of further study, as it may provide important clues to asthma health disparities. Juan C. Celedo´ n, MD, DrPH, FCCP Scott T. Weiss, MD, MS, FCCP Harvard Medical School Boston, MA Michelle M. Cloutier, MD Connecticut Children’s Medical Center Storrs, CT Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail:
[email protected]). Correspondence to: Juan C. Celedo´ n, MD, DrPH, FCCP, Assistant Professor of Medicine, Brigham & Women’s Hospital, 181 Longwood Ave, Boston, MA 02115-5804; e-mail: juan.celedon@ channing.harvard.edu
References 1 Celedo´ n JC, Sredl D, Weiss ST, et al. Ethnicity and skin test reactivity to aeroallergens among asthmatic children in Connecticut. Chest 2004; 125:85–92 2 Joseph CLM, Ownby DR, Peterson EL, et al. Racial differences in physiologic parameters related to asthma among middle-class children. Chest 2000; 117:1336 –1344 www.chestjournal.org
We read with great interest the article by Herth et al1 (January 2004), which reports the results of a randomized trial comparing conventional vs endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) of mediastinal lymph nodes (LNs). This is a very intriguing study, in which the authors performed TBNA during flexible or rigid bronchoscopy, and separately randomized and analyzed the results of the TBNA procedures obtained from different LN stations. In a first group, they included exclusively the subcarinal nodes, since they are easily accessible by any method. In a second group, they included all the TBNAs performed in the following LN stations according to the American Thoracic Society classification2: 2 (right and left); 3, 4 (right or left); and 5. The conclusions and the comments of this study contain some very important issues for bronchoscopists who routinely perform TBNA, and therefore deserve a few comments. The authors conclude that “EBUS guidance significantly increases the yield of TBNA in all lymph node stations except in the subcarinal one.” However, the data as proposed in Table 2 of their study show that similar diagnostic yields were obtained by both conventional and EBUS-guided TBNA also in the lower paratracheal area (4 right, 4 left). By considering these data, it looks like blind TBNA procedures proved as effective as ultrasound-guided ones in those stations (4 right, 4 left, 7), among those accessible to TBNA, where the majority of metastasis from non-small cell lung cancer (NSCLC) occurs.3,4 This result is not surprising if one takes into account the fact that the abovementioned LN areas (mainly 4R and 7) have been associated with very high (approximately 70%) diagnostic yields of conventional TBNA in several comprehensive studies in the settings of both malignant5,6 and benign diseases.7 A definite advantage was associated with ultrasound guidance only for TBNAs performed in LN stations (2, 3) less frequently involved by the metastatic spread of NSCLC, which is the most common indication to TBNA in clinical practice.8 The article also shows that 21 of 50 TBNA procedures in the non-subcarinal group were performed in the aortopulmonary window (APW), also called the subaortic station (station 5), which to the best of our knowledge is not accessible to TBNA. According to the American Thoracic Society LN map definition,2 the APW nodes “. . . are lateral to the ligamentum arteriosum or the aorta or the left pulmonary artery. . . ” and are therefore not in contact with the airways. In a recent review9 on invasive mediastinal staging of NSCLC, it is stated that the possible ways to access the APW nodes are the following: anterior mediastinotomy (also known as the Chamberlain procedure), extended cervical mediastinoscopy, thoracoscopy, and transesophageal endoscopic ultrasound with fine-needle aspiration. Is it possible that these 21 TBNA procedures were performed in the left paratracheal area? Another important aspect that is dealt with by Herth and colleagues is concerned with the significance of a TBNA aspirate yielding lymphocytes only, a finding basically meaning that the LN has been likely punctured.10 Interestingly, they observed that no patients with lymphocytes only on TBNA had a more specific diagnosis after subsequent surgical biopsy. We have proposed, albeit arbitrarily, that at least 30% of cellularity be composed of lymphocytes in order to consider adequate a TBNA cytology specimen.6,7 By using this quantitative cut-off value, two of nine adequate negative TBNA cytology specimens (23%) were subsequently shown to be false-negative at mediastinoscopy in a study on CHEST / 126 / 3 / SEPTEMBER, 2004
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Racial Differences in Allergen Sensitivity Christine L.M. Joseph, Edward L. Peterson, Christine C. Johnson and Dennis R. Ownby Chest 2004;126; 1004-1005 DOI 10.1378/chest.126.3.1004 This information is current as of July 13, 2011 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/126/3/1004.full.html References This article cites 2 articles, 2 of which can be accessed free at: http://chestjournal.chestpubs.org/content/126/3/1004.full.html#ref-list-1 Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.
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