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higher- and lower-starting-dose protocol patients, 98.4% dis-
charged with an aspirin prescription were still taking aspirin at 1
month, indicating low rates of long-term hypersensitivity-related
adverse events.
Our study shows that higher-starting-dose protocols (chal-
lenge or challenge-desensitization) for aspirin allergic patients
with CAD without a history of anaphylaxis can be as safe and
effective as lower-starting-dose protocols. Our center showed
success in a large number of patients with ACS, in most cases
before cardiac revascularization, without an increase in adverse
cardiovascular outcomes. There was a high median and cumula-
tive aspirin dose at reaction for all protocols, providing further
evidence that low starting doses are unnecessary. Our findings
support our center’s trend of replacing lower-starting-dose with
higher-starting-dose protocols, achieving aspirin’s antiplatelet
effect more quickly.
Emily H. Liang, MD
*
Cy Y. Kim, MD
y
Javed Sheikh, MD
*
Shefali A. Samant, MD
*
*
Department of Clinical Immunology and Allergy, Southern California
Permanente Medical Group, Los Angeles, California
y
Department of Cardiology, Southern California Permanente Medical
Group, Los Angeles, California
Shefali.A.Samant@kp.org
References
1. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 ACC/AHA guideline for
the management of patients with non-ST-elevation acute coronary syn-
dromes: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. Circulation. 2014;130:
2354e2394.
2. Feng CH, White AA, Stevenson DD. Characterization of aspirin allergies in
patients with coronary artery disease. Ann Allergy Asthma Immunol. 2013;
110(2):92e95.
3. Wong JT, Nagy CS, Krinzman SJ, et al. Rapid oral challenge-desensitization for
patients with aspirin-related urticaria-angioedema. J Allergy Clinc Immunol.
2000;105:997e1001.
4. Cortellini G, Caruso C, Romano A. Aspirin challenge and desensitization: how,
when and why. Curr Opin Allergy Clin Immunol. 2017;17:247e254.
5. Cortellini G, Romano A, Santucci A, et al. Clinical approach on challenge and
desensitization procedures with aspirin in patients with ischemic heart disease
and nonsteroidal anti-inflammatory drug hypersensitivity. Allergy. 2017;72:
498e506.
6. Rossini R, Iorio A, Pozzi R, et al. Aspirin desensitization in patients with cor-
onary artery disease: results of the multicenter ADAPTED registry. Circ Car-
diovasc Interv. 2017;10:e004368.
7. Chopra AM, Diez-Villanueva P, Cordoba-Soriano JG, et al. Meta-analysis of
acetylsalicylic acid desensitization in patients with acute coronary syndrome.
Am J Cardiol. 2019;124(1):14e19.
8. Lee RU, Stevenson DD. Aspirin-exacerbated respiratory disease: evaluation and
management. Allergy Asthma Immunol Res. 2011;3(1):3e10.
9. White AA, Stevenson DD, Woessner KM, et al. Approach to patients with
aspirin hypersensitivity and acute cardiovascular emergencies. Allergy Asthma
Proc. 2013;34:138e142.
10. Al-Ahmad M, Rodriguez-Bouza T, Nurkic M. Establishing a safe administration
of ASA in cardiovascular patients with nonsteroidal anti-inflammatory drug
hypersensitivity with skin and/or respiratory involvement. Int Arch Allergy
Immunol. 2018;175:237e245.
Unexpected and unintended cure of habit cough by proxy
In 1966, Dr Bernie Berman, a Boston allergist, described 6 children
with a chronic cough that could be stopped by “the art of sugges-
tion.”Dr Berman called this a habit cough.
1
This disorder has been
repeatedly described, sometimes with different terms but with the
same description of the characteristic sound of the cough, barking
or honking, and the absence of the cough once asleep.
2-8
The
frequency of habit cough diagnoses was reported at the rates of 7
per year at the University of Iowa
6
and 9 per year at the Brompton
Hospital in London England.
7
A median age for children with the
diagnosis was 10 years at both institutions.
8
Treatment at the
University of Iowa consisted of suggestion therapy. In 1991, I
described 9 patients who were successfully treated with suggestion
therapy. Seven who could be contacted, even years later, had sus-
tained benefit. Subsequently, I reviewed our experience with 140
children seen from 1995 to 2014. Among 85 of those children who
were coughing when seen in the clinic, cessation of cough with
suggestion therapy was successful in 81. In this letter, I present
some unexpected and unintended additional observations related
to this disorder.
In early February 2019, I received an e-mail from the father of
a 12-year-old girl with a 3-month history of a repetitive daily
cough that was absent once asleep. His online search for help led
to me. He and his daughter were at a location 3000 miles from
me. Her pediatric pulmonologist was prescribing inhaled corti-
costeroids, which were providing no benefit. Because she met the
criteria for habit cough, I undertook, for the first time, delivering
my usual suggestion therapy
9
via Skype. Cessation of cough
occurred within 15 minutes. The girl’s father recorded the pro-
cedure and created a website (www.habitcough.com)that
contained his daughter’s history and an audiovisual recording.
The full video was also placed on YouTube (https://www.
youtube.com/watch?v¼jnQUvD8Qdj0&t¼670s).
Although the outcome of this patient’s treatment via Skype was
a satisfying experience, an unexpected and unintended effect of the
video was subsequently reported to me. I received unsought
e-mails from the parents of 3 children and 2 adults, indicating that
watching the young girl respond to suggestion therapy in the video
resulted in cessation of their chronic cough.
The first of individuals these reached me in early April 2019.
The mother of a 10-year-old boy described her previously healthy
son who developed a dry hacking cough “that has not stopped,
except at night when he’sasleep”after a viral illness 2 months
earlier. His pediatrician prescribed steroids, azithromycin, 3
different antihistamines, montelukast (Singulair), amoxicillin and
clavulanate (Augmentin), albuterol and beclomethasone (QVAR),
benzonatate (Tessalon Perles), dextromethorphan (Robitussin
DM), and honey, with no benefit. Chest radiography and labo-
ratory tests provided no diagnosis. The mother, a pediatric nurse,
had seen the video at www.habitcough.com and asked her son to
sit by her and watch the video. The mother indicated that “he
immediately identified with [the patient]; he jumped right into it
and stopped coughing.”An e-mail more than a month later
indicated that the previous coughing was still no longer present.
In May 2019, a mother of an 8-year-old girl sent me an e-mail
describing her daughter as having a bad cold several months
earlier that was followed by 2 months of a persistent daily cough
characteristic of the habit cough. Her physician obtained chest
radiography and prescribed “asthma and allergy medications”
without benefit. A pulmonologist told her daughter to “take
some ice water when you feel the cough coming on.”None of the
measures were of benefit. Searching for help on the internet, the
mother found the video on YouTube. While the 2 of them
watched the suggestion therapy procedure on the video, her
daughter commented excitedly, “I can hold the cough back.”This
Disclosures: The author has no conflicts of interest to report.
Funding: None.
Letters / Ann Allergy Asthma Immunol 123 (2019) 507e525 515
was followed by cessation of coughing. Mother stated, “THE
COUGHING STOPPED! Like turning off a switch.”A subsequent
e-mail from the mother reported that the cough was still gone 4
days later.
In June 2019, I received an e-mail from the father of a 9-year-old
boy with a history of motor and vocal tics who had a persistent
repetitive chronic dry cough. The father indicated that the cough
occurred several times per minute and was not present when
asleep. When watching the video, the boy first stated, “It’s different
than mine,”but then associated what he was observing with his
own condition and found he could suppress the cough. The cough
was still gone the following day.
I also received e-mails from 2 adult women, 58 and 68 years old.
They both indicated that watching the 30-minute video and
following along with the dialogue resulted in cessation of their
chronic cough. One of the women stated, “I listened to the video
and concentrated. It really works.”The other woman commented,
“It’s amazing; mind over matter?”
Habit cough causes considerable morbidity, including well-
intentioned iatrogenesis, unneeded testing, unnecessary medi-
cation, and even hospitalization.
9
Several variations of suggestion
are well documented as curative for habit cough.
1,4,5,8
The
current unanticipated and unintended observations reported in 3
children and 2 adults demonstrate further the amenability of
habit cough to suggestion. The clinical characteristics of
habit cough are sufficiently distinct that the diagnosis can be
made by the typical history of a repetitive harsh, barking, or
honking cough, occurring up to several times per minute, that is
absent once asleep. No testing is needed for diagnosis, and no
medications are needed for treatment. Knowledge and skillful
interaction with the patient are the tools for diagnosing and
treating this disorder.
Miles Weinberger, MD
Department of Pediatrics
University of California, San Diego
Rady Children’s Hospital
Encinitas, California
miles-weinberger@uiowa.edu
References
1. Berman BA. Habit cough in adolescent children. Ann Allergy. 1966;24:43e46.
2. KravitzH, Gomberg RM, Burnstine RC, Hagler S, Korach A. Psychogenic cough tic in
childrenand adolescents:nine case historiesillustrate the needfor re-evaluation of
this common but frequently unrecognized problem. Clin Pediatr. 1969;8:580e583.
3. Weinberg EG. “Honking”: psychogenic cough tic in children. S Afr Med J. 1980;
57:198e200.
4. Lokshin B, Lindgren S, Weinberger M, et al. Outcome of habit cough in children
treated with a brief session of suggestion therapy. Ann Allergy. 1991;67:
579e582.
5. Cohlan SQ, Stone SM. The cough and the bedsheet. Pediatrics . 1984;74:
11e15.
6. Weinberger M, Hoegger M. The cough without a cause: habit cough syndrome.
J Allergy Clin Immunol. 2016;137:930e931.
7. Wright MFA, Balfour-Lynn IM. Habit-tic cough: presentation and outcome with
simple reassurance. Pediatr Pulmonol. 2018;53:512e516.
8. Anbar RD, Hall HR. Childhood habit cough treated with self-hypnosis. Pediatrics.
2004;144:213e217.
9. Weinberger M. Commentary: the habit cough: diagnosis and treatment. Pediatr
Pulmonol. 2018;53:535e537.
The practical clinical relevance of rhinitis classification in children
with asthma
outcomes of the “ControL’Asma”study
Asthma and rhinitis may share pathogenic mechanisms, and
extensive investigation has been devoted to exploring their
reciprocal impact. A recent prospective study investigated the
prevalence of rhinitis and its phenotypes, symptom severity, and
medication use in 619 children with asthma.
1
Rhinitis was found to
be a common asthma comorbidity (93.5%) and was refractory to
standard rhinitis medications. Perennial allergic rhinitis with sea-
sonal exacerbation caused by poly-allergy was common (34.2%),
mostly severe, and often associated with difficult-to-control
asthma. In line with previous evidence,
2,3
the study concluded
that poly-allergy should be considered a significant risk factor for
poor control of asthma.
The Italian Society of Paediatric Allergy and Immunology
recently established a Study Group (“ControL’Asma”) to evaluate
asthma control in children managed in clinical practice. In this
context, the group considers rhinitis a comorbidity worthy of
investigation. We therefore conducted a study aimed at evaluating
the prevalence and impact of rhinitis and its phenotypes on asthma
outcomes in a large group of children with asthma.
We enrolled and visited 333 children across 10 Italian pae-
diatric allergy centers. Information was gathered about asthma
duration, asthma control levels, and asthma severity grade ac-
cording to the Global Initiative for Asthma (GINA) guidelines.
4
Emergency department admissions, absences from school,
current use of medications, including inhaled and oral cortico-
steroids, were also reported, and also body mass index (BMI)
assessment. lung function testing, fractinoal exhaled nitric oxide
(FeNO) measurement, and children’s asthma control test score
(c-ACT). Children self-administered the children asthma control
test (c-ACT) questionnaire. The Review Ethics Committees
approved the study procedure, and written informed consent
was obtained from the parents of all children. Clinical data were
recorded on an electronic case report form approved for this
study.
Demographic and clinical characteristics are described using
means with standard deviation for normally distributed continuous
data (eg, age), medians with lower and upper quartiles for not
normally distributed data (eg, FeNO levels), and absolute frequency
and percentages for categorical data (eg, frequency of male sub-
jects). The normality of distribution was assessed by Shapiro-Wilk
W test. Normally distributed quantitative data were analyzed
using analysis of variance (ANOVA) followed by a Sheffè post hoc
test, and non-normally distributed quantitative data using a
Kruskall-Wallis test followed by Bonferroni’s correction. Compari-
son of frequency distributions was made by means of the
c
2
test or
Fisher’s exact test in case of expected frequencies less than 5,
followed by Bonferroni’s correction. Statistical significance was set
Disclosures: None.
Funding Sources: None.
“ControL’Asma Study Group”members: Elisa Anastasio, Ilaria Brambilla, Carlo
Caffarelli, Loredana Chini, Riccardo Ciprandi, Paolo Del Barba, Valentina De Vittori,
Maria Elisa Di Cicco, Luciana Indinnimeo, Ahmad Kantar, Maddalena Leone, Amelia
Licari, Viviana Moschese, Roberta Olcese, Diego Peroni, Angela Pistorio, Michela
Silvestri, Anna Maria Zicari.
Author’s contribution: MAT, MD, GM, and GC designed the study, GC wrote the
manuscript.
Letters / Ann Allergy Asthma Immunol 123 (2019) 507e525516