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Introduction: Atopic dermatitis (AD) has a complex pathophysiology. The course of the disease is affected by both environmental factors and allergen hypersensitivities. Food and aeroallergens have a significant role in the pathogenesis and disease control. Objective: In this study, it was aimed to determine the prevalence of food and aeroallergen sensitivity of children with AD. Methods: Children under 18 years with AD who applied to pediatric allergy and immunology outpatient clinics were evaluated. All patients had a skin prick test (SPT) within most common food and aeroallergens. Results: One hundred seventy three patients were studied. Most of the moderate and severe AD patients were boys (boys 64% vs. girls 47%). Symptoms started earlier and positive results in SPTs with food allergens were more common in patients with SCORAD (SCORing Atopic Dermatitis) >25 (p < 0.0001). Egg white (39%), egg yolk (31%), cow’s milk (13%) and wheat flour (5%), were the most common allergens, respectively. The SCORAD scores were higher in multiple food sensitized patients’ groups (p < 0.001). Although, food sensitizations were prevalent in patients who had higher SCORAD scores (p = 0.001), there was no significant difference in sensitization with aeroallergens. (p = 0.392). Conclusion: Sensitizations to both food and aeroallergens are common in patients with AD. In addition, sensitization to these allergens and SCORAD severity in patients with AD have positive correlation.

Introduction: Beta-lactam (BL) antibiotics are the most often involved drugs in allergic reactions. Mild cutaneous reactions such as maculopapular exanthema or urticaria are the most common presenting complaints of BL allergy in the pediatric population. However, it can be challenging to distinguish BL-induced allergy from reactions due to infections or other reasons. In this study, we aimed to determine the clinical characteristics and potential risk factors of true BL allergy in children with suspected mild cutaneous reactions to BLs. Methods: We evaluated children who were admitted to our pediatric allergy clinic with suspected BL allergy in between January 2015 and March 2020. Patients with a history suggestive of immediate and non-immediate mild cutaneous reactions were included in the study. The oral challenge test (OCT) with the culprit drug was performed on all patients to confirm the diagnosis. Results: Two hundred fourteen (119 male and 95 female) patients with a median age of 4.9 years were evaluated. BL allergy was confirmed in 10.7% (23) of the patients, according to the OCT results. Most of the proven allergic reactions were of the immediate type (73.9%), and urticaria was the most common presenting complaint (60.8%) in proven BL-allergic patients. The negative predictive value of penicillin-G skin testing was 89.7% for immediate-type penicillin allergy and 93.4% for non-immediate reactions. Also, positive predictive value of penicillin-G skin testing was 50% for immediate and 25% for non-immediate reactions. In the multivariate logistic regression analysis, a history of proven drug allergy (Exp (B): 7.76, 95% CI: 1.88–31.97, p = 0.005) was found to be the risk for BL allergy. Conclusion: This study highlighted that OCTs should be performed to confirm the diagnosis in patients suspected of immediate and non-immediate mild cutaneous reactions to BLs and remove the overestimated “BL allergy” label. In these patients, a history of proven drug allergy might be a risk factor for true BL allergy.

Introduction: Ibuprofen is the most common culprit drug causing nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity in children. We aimed to evaluate the frequency, clinical characteristics, and risk factors of confirmed ibuprofen allergy in children presenting with a history of suspected immediate type ibuprofen-induced hypersensitivity reactions. Methods: We evaluated 50 (35 M, 15 F) children with a median age of 7 years, who were referred to our clinic with suspected immediate ibuprofen hypersensitivity. Patients were subjected to a diagnostic work up including drug provocation tests (DPTs) with the culprit drug. Reactions were classified according to the European Academy of Allergy and Clinical Immunology Task Force recommendations for pediatric patients. Proven ibuprofen allergic patients underwent DPT to find a safe alternative drug. Results: Ibuprofen allergy was confirmed in 34% (n: 17) of children; 9 patients were diagnosed by DPTs and 8 patients diagnosed based on their histories. Angioedema was the most common clinical manifestation (n: 30, 60%). Among patients with proven ibuprofen allergy, 7 of them were classified as cross-intolerant. Cross-intolerance reactions were further classified as NSAID-exacerbated cutaneous disease (n = 1) and NSAID-induced urticaria/angioedema/anaphylaxis (n = 6). As an alternative drug, paracetamol was safely tolerated, whereas 1 patient developed angioedema and urticaria with nimesulide. Older age and male gender were identified as independent risk factors for immediate-type ibuprofen allergy. Conclusion: DPTs should be performed to confirm or exclude ibuprofen allergy in children and to find safe alternative drugs. Male gender and older age are risk factors for ibuprofen allergy. NSAID-induced hypersensitivity reactions in the pediatric population cannot be well defined using the adult classification system.

Cetirizine is a selective H1 histamine receptor antagonist derived from piperazine. Piperazine is a cyclic moiety molecule located in the structure of many drugs, including anxiolytics, antidepressants, and antipsychotics. Drug-induced dystonia is reported mostly due to antipsychotic and antiemetic drugs. It occurs due to the disruption of dopamine and acetylcholine balance in favor of acetylcholine. Although cetirizine is a relatively safe drug, it has rarely been reported to cause a dystonic reaction. To the best of our knowledge, there is no reported case of dystonia due to cetirizine in infancy. Here, we present a 7-month-old patient who developed a dystonic reaction after cetirizine administration., Setirizin, piperazinden türetilen seçici bir H1 histamin reseptör antagonis- tidir. Piperazin, anksiyolitikler, antidepresanlar ve antipsikotikler dahil olmak üzere birçok ilacın yapısında yer alan siklik bir moleküldür. İlaca bağlı distoni, çoğunlukla antipsikotik ve antiemetik ilaçlara bağlı olarak bildirilmektedir. Dopamin ve asetilkolin dengesinin asetilkolin lehine bozulması sonucu oluşur. Setirizin nispeten güvenli bir ilaç olmasına rağ- men, nadiren distonik reaksiyona neden olduğu bildirilmiştir. Şimdiye kadar süt çocukluğu döneminde setirizine bağlı olarak bildirilmiş bir dis- toni vakası yoktur. Burada setirizin uygulaması sonrası distonik reaksiyon gelişen 7 aylık bir hasta sunulmuştur.

To understand facilitators, barriers, and perceptions of the Every Second Matters uterine balloon tamponade (ESM-UBT) package implemented across 10 medical colleges in India, 3 years after the program was introduced.Semi-structured interviews were conducted until thematic saturation in March 2020. Multiple provider cadres, including nurses, Obstetrics/Gynecology residents, professors, and program leads, were eligible. Interviews were transcribed and thematically coded using an inductive method.Sixty-two obstetric providers were interviewed. Facilitators of implementation included recurrent training, improved teamwork and communication, strong program leadership, and involvement of lower-level facilities. Barriers to implementation included administrative hurdles, high staff turnover, language barriers, and resources required to reach and train lower-level facilities. Overall, the majority of clinicians viewed the ESM-UBT package as a useful intervention in aiding efforts to reduce maternal deaths from postpartum hemorrhage.Among 10 medical colleges in India the ESM-UBT package is seen as a beneficial intervention for managing refractory atonic postpartum hemorrhage, and for reducing maternal morbidity and mortality. Identified facilitators of and barriers to implementation of the ESM-UBT package in India should be used to guide future implementation efforts.

Background: Cow's milk is one of the most common of the foods that cause food allergies in children. Here, we present a 10-month-old male who was diagnosed with having an allergy to cow's milk and who developed an anaphylactic reaction after being recently vaccinated with a measles vaccine. Case: The patient had been diagnosed with atopic dermatitis and cow's milk allergy at 40 days old after a rash appeared on his face and arms while exclusively breastfeeding. At 9 months, on his routine welfare outpatient appointment, he developed a facial rash and swelling, wheezing, difficulty breathing, and cyanosis within 10 min of having his first measles vaccination (M-VAC(®); Serum Institute of India, Hadapsar, Pune, India). After an allergy evaluation and a physical examination that showed that he was otherwise healthy, he was diagnosed with an allergy to cow's milk, which was then eliminated from his diet. Laboratory evaluations were as follows: serum immunoglobulin E (IgE) to cow's milk: 36.2 kU/L, α-lactalbumin: 9.39 kU/L, β-lactoglobulin: 8.74 kU/L, casein: 34.2 kU/L, latex-specific (sp)IgE: 0.10 kU/L, gelatin spIgE

Amaç: Bu çalışmada amacımız okul öncesi astımlı çocuklarda yatmadan önceki son beslenme saati, uykuda beslenmeleri, gece yatma saati, sabah kalkma saati ve sosyal çevresi ile ilgili faktörlerin üst solunum yolu semptomları ve astım kontrolü üzerine etkilerini araştırmaktadır. Gereç ve Yöntem: Çalışma, okul öncesi astımlı çocuklar ile benzer cinsiyet, yaş dağılımına sahip sağlıklı çocuklarda yapıldı. Bulgular: Çalışma gurubuna 103’ü (%47,5) astım, 114’ü (%52,5) sağlıklı olmak üzere 217 çocuk alındı. Gece yatmadan önce son 2 saat içinde beslenme sıklığı astımlı çocuklarda %47,6 iken sağlıklı çocuklarda %82,5 idi (p, Objective: In this study, our aim was to investigate the effects of feeding habits such as the last feed before bedtime, feeding during sleep, bedtime, waking time and factors associated with the social environment on upper airway tract symptoms and asthma control. Material and Method: The study was conducted on children with preschool asthma and their age and sex matched healthy children. Results: The study group included 217 children, 103 of whom have asthma and 114 were (52.5%) healthy. The frequency of feeding in the last 2 hours before going to bed was 47.6% in children with asthma and 82.5% in healthy children (p

Background Clarithromycin hypersensitivity is reported as the most common cause of non-β-lactam antibiotic allergy in children. Clarithromycin is frequently prescribed in cases of suspected β-lactam hypersensitivity. Oral provocation tests stand as the gold standard to confirm drug hypersensitivity as diagnostic value of skin tests is variable. We analyzed the frequency of true clarithromycin hypersensitivity ratio and its relationship with β-lactam allergy among children with suspected clarithromycin hypersensitivity and evaluated the diagnostic value of skin tests. Methods The study included 160 children referred with suspected clarithromycin hypersensitivity. Clinical history and allergy workups including skin tests or/and oral provocation tests were retrieved from medical records. Results Oral provocation test confirmed clarithromycin hypersensitivity rate was 5.6% (n = 9/160). Skin tests with clarithromycin showed positivity in 32.6% (n = 29/89) of the tested patients. The sensitivity of clarithromycin skin tests was negligible, and specificity was 73.9% (95% confidence interval [CI], 64.7-81.8). Eighty-eight of the patients (55%) reported that they had previously tolerated a β-lactam antibiotic. β-lactam hypersensitivity was suspected in 40% (n = 64/160) of the patients (simultaneous [n = 10], sequential [n = 19], distant form [n = 35]) in relation with clarithromycin usage. β-lactam hypersensitivity (95% CI, 2.1-70.6, p = .005) and sequential usage of clarithromycin after the development of a rash with amoxicillin-clavulanic acid (95% CI, 2.0-96.4, p = .007) were found as risk factors for confirmed clarithromycin hypersensitivity. Conclusion The frequency of confirmed clarithromycin hypersensitivity was found low among suspected patients. Oral provocation test is crucial for definite diagnosis. Confirmed β-lactam allergy may be attributed as a risk factor for clarithromycin hypersensitivity, particularly clarithromycin treatment after a developing rash with amoxicillin-clavulanic acid in sequential usage.

Clarithromycin and azithromycin are the most frequently prescribed oral macrolide antibiotics for children. Macrolides are relatively safe antibiotics due to their low allergenicity, but are nevertheless known to cause hypersensitivity reactions. Azithromycin appears to be responsible for severe reactions more often than clarithromycin. The most common reactions are maculopapular exanthems, and macrolide-induced anaphylaxis is exceptionally rare. Skin tests are not enough for the diagnosis of macrolide allergies, and oral provocation tests are necessary for a definite diagnosis. Here, we present a case of anaphylaxis during oral provocation with azithromycin, in which intolerance to amoxicillin-clavulanic acid and clarithromycin have been verified by provocation testing previously.

The purpose of this review is to understand the minimally invasive approach to the excision and repair of an isthmocele.Previous small trials and case reports have shown that the minimally invasive approach by hysteroscopy and/or laparoscopy can cure symptoms of a uterine isthmocele, including abnormal bleeding, pelvic pain and secondary infertility. A recent larger prospective study has been published that evaluates outcomes of minimally invasive isthmocele repair. Smaller studies and individual case reports echo the positive results of this larger trial.The cesarean section scar defect, also known as an isthmocele, has become an important diagnosis for women who present with abnormal uterine bleeding, pelvic pain and secondary infertility. It is important for providers to be aware of the effective surgical treatment options for the symptomatic isthmocele. A minimally invasive approach, whether it be laparoscopic or hysteroscopic, has proven to be a safe and effective option in reducing symptoms and improving fertility. VIDEO ABSTRACT: http://links.lww.com/COOG/A37.

Çalışmamızda Otolog serum testi pozitifliği ile çocukluk çağı kronik spontan ürtikerinin ağırlığı arasındaki ilişkiyi araştıran kısıtlı sayıda çalışmaya katkıda bulunmak amaçlanmıştır. Kronik spontan ürtiker nedeniyle otolog serum testi yapılmış 87 çocuk hastanın verileri geriye dönük incelendi. Ürtiker ağırlığı ürtiker aktivite skoruna göre değerlendirildi. Hastalarımızın 19’ında (%21.83) otolog serum testi pozitif olarak tespit edildi. Otolog serum testi pozitif ve negatif olan hastaların klinik ve laboratuvar parametreleri değerlendirildiğinde; yaş, cins, semptomların başlama yaşı, total IgE ve eozinofil (%) açısından istatistiksel anlamlılık saptanmadı. Otolog serum testi pozitif olan hastaların ürtiker aktivite skorları anlamlı olarak daha yüksek saptandı (p 0,001). Çalışmamızda otolog serum testipozitif hastalarda ürtiker aktivite skoru daha yüksek bulunmuştur. Pozitif otolog serum testine sahip hastaların tedavi seçimi hastalığın daha şiddetli olabileceği ihtimalini dikkate alarak yapıldığında daha çabuksemptom kontrolünü ve hastaların yaşam kalitesinin düzelmesini sağlayacaktır. We aimed to contribute to the limited number of studies that investigated the association between autologous serum test positivity and the severity of childhood chronic spontaneous urticaria. : Eighty-seven pediatric patients who underwent autologous serum test for chronic spontaneous urticaria were retrospectively investigated. Urticaria severity was assessed according to urticaria activity score. : In 19 of our patients (21.83%), the autologous serum test was positive. When clinical and laboratory parameters of patients with positive and negative autologous serum test are evaluated; age, sex, onset of symptoms, total IgE and eosinophil (%) were not statistically significant. Patients with positive autologous serum test had significantly higher urticaria activity scores (p 0.001).v: In our study, urticaria activity score was found higher in patients with autologous serum test positive. The choice of treatment for patients with a positive autologous serum test will ensure that symptoms and the quality of life of the patients will be improved faster if they are taken into consideration that the disease may be more severe.

Background Paracetamol, a non-steroidal anti-inflammatory drug, is commonly being used for fever and pain relief worldwide. The aim of this study was to evaluate children with a suspected history of paracetamol hypersensitivity. Methods Sixty patients who were referred to our clinic in between January 2015 and December 2018 with a suspected history of paracetamol hypersensitivity were included. Reactions were classified according to the European Network for Drug Allergy (ENDA)/Global Allergy and Asthma European Network classification and European Academy of Allergy and Clinical Immunology (EAACI)/ENDA Position Paper. Diagnoses were confirmed by skin tests and oral challenge tests (OCTs). In those with verified paracetamol hypersensitivity, an OCT with a strong COX-1 inhibitor was performed to classify the type of the reaction to refer as either selective or cross-intolerance hypersensitivity. A subsequent OCT with a selective COX-2 inhibitor was performed in those cross-intolerant patients to find out a safe alternative drug. Results Sixty OCTs with paracetamol were performed to patients with a median age of 8.5 years, and hypersensitivity to paracetamol was verified in 8 patients. Four children were classified as selective responders, and 3 were classified as cross-intolerant after OCT with a COX-1 inhibitor. Overall, skin test positivity for paracetamol was detected in only one patient, in whom OCT with paracetamol was negative. In all 3 cross-intolerant patients, a safe alternative non-steroidal anti-inflammatory drug was identified after an OCT with a selective COX-2 inhibitor. Conclusion OCT stands as the gold-standard procedure in verifying the diagnosis of patients with paracetamol-induced drug hypersensitivity, as well as, in defining the type of reactions and finding out safe alternative drugs.

Background Beekeepers and their families are at an increased risk of life-threatening anaphylaxis due to recurrent bee-sting exposures. Objective The aim of this study is to evaluate the demographic features, previous history of anaphylaxis among beekeepers and their family members, and their knowledge about the symptoms and management of anaphylaxis. Methods A standardized questionnaire was administered to beekeepers during the 6th International Beekeeping and Pine Honey Congress held in 2018, in Mugla, Turkey. Additionally, food-service staff from restaurants were surveyed as an occupational control group about their knowledge about anaphylaxis. Results Sixty-nine beekeepers (82.6% male, mean age 48.4 ± 12.0 years) and 52 restaurant staff (46.2% male, mean age 40.5 ± 10.0 years) completed the questionnaire. Awareness of the terms ‘anaphylaxis’ and ‘epinephrine auto-injector’ among the beekeepers were 55.1% and 30.4% and among the restaurant staff were 23.1% and 3.8%, respectively. Of the beekeepers, 74% were able to identify the potential symptoms of anaphylaxis among the given choices; 2.9% and 5.8% reported anaphylaxis related to bee-stings in themselves and in their family members, respectively. None of the restaurant staff had experienced or encountered anaphylaxis before but 3.8% of their family members had anaphylaxis and those reactions were induced by drugs. Conclusion It is essential that implementation of focused training programs about anaphylaxis symptoms and signs as well as practical instructions of when and how to use an epinephrine auto-injector will decrease preventable morbidities and mortalities due to bee-stings in this selected high-risk population of beekeepers and their family members, as well as other fieldworkers under risk.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most commonlyused drugs in childhood and are the second most common drugs after antibiotics indrug related hypersensitivity reactions. NSAIDs induce hypersensitivity reactionsin sensitive individuals varying in timing, organ involvement and severity. Hypersensitivity reactions to NSAIDs are classified as allergic (caused by immunological mechanism) and non-allergic (non-immunological) reactions according to the underl-ying mechanism. The diagnosis of NSAIDs hypersensitivity is usually based on clinical history, but patients who have been evaluated with history alone may be misdiagnosed as drug allergy. It is recommended to evaluate the patient with detailedhistory, physical examination and standardized diagnostic tests for definitive diagnosis., ÖzNon-steroidal antiinflamatuar ilaçlar (NSAİİ), çocukluk çağında en sık kullanılan ilaçlar arasındadır ve ilaç ilişkili aşırı duyarlılık reaksiyonları içinde antibiyotiklerden sonra ikinci sırada yer almaktadır. Duyarlı bireylerde zamanlaması, organ tutulumu ve şiddeti değişen aşırı duyarlılık reaksiyonlarına neden olmaktadır. Aşırı duyarlılık reaksiyonları altta yatan mekanizmaya göre alerjik (immünolojik mekanizma ile oluşan) ve alerjik olmayan (non-immünolojik) reaksiyonlar olarak ikiye ayrılır. Tanı genellikle öyküye dayanmaktadır, ancak tek başına öykü ile değerlendirilen hastalar yanlışlıkla ilaç alerjisi tanısı alabilmektedir. Kesin tanı için hastanın ayrıntılı öykü, fizik muayene ve standardize edilmiş tanısal testler ile birlikte değerlendirilmesi önerilmektedir.

Background Atopic dermatitis is a common illness in childhood. Children with atopic dermatitis are prone to develop cutaneous sensitization due to skin barrier dysfunction. Aim The aim of this study was to evaluate the frequency of cutaneous sensitizations in patients with atopic dermatitis and to identify the most frequent causative allergens. Study design The study group consisted of 112 children with atopic dermatitis, aged 1–18 years (median 88.5 months) and 39 healthy controls, aged 1–8 years (median 88.48 months). Methods The diagnosis of atopic dermatitis was established by modified Hanifin and Rajka criteria; severity of the disease was assessed by scoring of atopic dermatitis. Serum blood eosinophil count, total IgE and skin prick tests for common aeroallergens and food allergens were performed. Patch tests with cosmetic series and European standard patch test series (Stallegenes© Ltd, Paris, France) were applied. Results Of the children with atopic dermatitis, 17% (n = 19) were sensitized to either cosmetic or standard series or both of them; no children in the control group had a positive patch test (p = 0.001). Atopy and severity of atopic dermatitis was not a significant risk factor for cutaneous sensitization. The most common allergens were Nickel sulphate and Methychloroisothiazinolone (4.5% and 4.5%) in the European standard patch test and cocamidoproplybetaine (12.5%) in the cosmetic series patch test. Conclusion Cutaneous sensitization can develop in children with atopic dermatitis, therefore allergic contact dermatitis should be kept in mind.

Introduction Periostin has some effects on the pathogenesis of atopic dermatitis (AD) via release of pro-inflammatory cytokines and chemokines from activated keratinocytes and it is related to chronicity of skin lesions. Aim To evaluate the relationship between plasma periostin levels and severity and chronicity of AD in children. Material and methods The study population consisted of 29 children with atopic dermatitis without concomitant allergic disease such as asthma or allergic rhinitis and 31 healthy controls. Data of demographic features, serum eosinophil, total IgE and skin prick test results were collected through the patient's medical records. The severity of the disease was assessed by the SCORAD index. Serum periostin levels were measured with a human periostin ELISA kit. Results The mean ages of the AD patients and the control group participants were 80.7 ±52.8 and 90.3 ±41.6 months, respectively. Mean plasma periostin levels were 63.0 ±19.0 ng/ml in AD patients, and 23.6 ±7.3 in healthy controls, and there was a statistically significant difference between the two groups (p = 0.001). Plasma periostin level did not vary according to total IgE or serum eosinophil count (p > 0.05). Age of onset and duration of symptoms also were not correlated with plasma periostin levels. Although there was a positive relationship between plasma periostin level and the SCORAD index of patients, it was not statistically significant (r = 0.19, p > 0.05). Conclusions This study showed that plasma periostin levels were increased in children with atopic dermatitis. Periostin may have a partial role in the pathogenesis of atopic dermatitis, but it is not associated with severity or chronicity in children with atopic dermatitis.

Anaphylaxis is a life-threatening, emergency clinic conditi- on, so it is essential to diagnose and treat anaphylaxis immediately. Adrenaline is the first choice in the treatment of anaphylaxis; it is the only drug that prevents death and hospitalization. It is also very important to prevent anaph- ylaxis as much as treatment, since it is not predictable when it will appear. Adrenaline auto-injectors AAI should be prescribed for individuals who have anaphylaxis and are at high risk for anaphylaxis, and they should be infor- med about when and how to use them. Generally, in adult and pediatric patients, administration of adrenaline in anaphylactic reactions is inadequate and AAI is prescribed at low rates for patients at risk of anaphylaxis

Sipahi S, Nacaroglu HT, Can D, Gunay I, Unsal-Karkiner CS, Kamali H, Ozdemir A, Gunay T. Effect of socioeconomic status on allergic diseases and atopy in school children. Turk J Pediatr 2017; 59: 670-677. Higher family socioeconomic status (SES) has been suggested as a risk factor for allergic diseases. We investigated the effect of SES on the prevalence of allergic diseases and atopy. The study included 13-14-year-old primary school students in Kemalpasa, Turkey. The International Study of Asthma and Allergies in Childhood phase 1 questionnaire was administered to all students to identify allergic diseases. Those identified as having allergic diseases underwent a skin prick test (SPT). Group I included students with allergic diseases and a positive SPT. Group II comprised students with allergic disease who were SPT negative. The control group was randomly selected from the students with no allergic diseases. Three weighted SES scores were calculated for each student (equally weighted, education-weighted, and social class-weighted). SES was classified as lower, middle, or upper according to the weighted SES scores. Allergic diseases were detected in 657 of the 1,373 children who participated in the study. A higher percentage of children with allergic diseases and atopy were in the lower SES group in all weighted SES analyses compared with controls (Group I: 59%, 83.1%, 67.5%; Group II: 62.9%, 80%, 63.5%; control group: 12.4%, 12.9%, 21.2%). Significantly more children with allergic and atopic diseases (Groups I and II) were in the lower SES group compared with the control group (p < 0.001). In contrast to the hygiene hypothesis, we found the incidence of atopic disease was higher in families with lower SES.