Tag Archives: asthma

Seeking Global Accord on Allergy

Four major professional allergy organizations have launched a new effort to raise worldwide awareness of allergic diseases.

The International Collaboration on Asthma, Allergy, and Immunology (iCAALL) is a project of the American Academy of Allergy, Asthma & Immunology (AAAAI), the American College of Allergy, Asthma & Immunology (ACAAI), the European Academy of Allergy and Clinical Immunology (EAACI), and the World Allergy Organization (WAO). The leaders of each group announced the new initiative at a press briefing held during the AAAAI’s annual meeting in Orlando. An editorial introducing the initiative is online and will be published in the April issue of the Journalof Allergy and Clinical Immunology.

“The world has experienced a tremendous increase in the prevalence of allergic diseases and asthma over the last 50 years,” EAACI president Dr. Cezmi Akdis said, noting that asthma currently affects 8%-12% of the developed world, and allergic rhinitis, approximately 20%-25%. Asthma care costs more than 20 billion Euros today and is expected to jump to 200 billion Euros in 2050. Yet, current research funding is only about 2%-3% of that devoted to diseases such as cancer and HIV/AIDS.

“We need better treatments and tailored care. We need more and more research … I am confident that iCAALL will result in a greater awareness about allergies, asthma, and immunologic diseases all around the world, resulting in prevention, cure, and better patient care, which is only possible by increased allocation of resources for research,” Dr. Akdis said.

According to WAO president Dr. Ruby Pawankar, “Allergies and asthma are no longer diseases of just the developed world … It’s a huge problem in the industrializing and the developing world.” She pointed out that allergic disease has been absent from the recent World Health Organization/United Nations focus on noncommunicable diseases (NCDs), highlighted by a high-level meeting last September.

“The WHO and UN have made efforts toward giving more attention to NCDs. However, the area of allergy and asthma and clinical immunologic diseases needs to get to the stage to be represented at the WHO and UN.” To that end, WAO has issued a White Book on allergic disease with reports from 62 member countries, Dr. Pawankar said.

Dr. Wesley Burks described the iCAALL centerpiece initiative, a series of International Consensus (ICON) reports. The first ICON, on food allergy, is already online. It includes breastfeeding in the first 4-6 months as a key recommendation for reducing the risk for allergic disease. Food allergy is rising worldwide; in China, for example, food allergy has almost doubled from 3.9% 10 years ago to 7.7% today. “In a country thought not to have a lot of food allergy, that’s a significant change,” said Dr. Burks, president-elect of AAAAI.

Dr. Stanley Fineman, ACAAI president, outlined the plans for dissemination of upcoming ICONs: One on pediatric asthma is to be released at the EAACI Congress  in June in Geneva; the next, on angioedema, at the ACAAI meeting in November in Anaheim, Calif.; and then one on eosinophilic disorders at the WAO’s International Scientific Conference in December in Hyderabad, India.

Dr. Dennis K. Ledford, outgoing AAAAI president and iCAALL chair, said that other initiatives will incorporate additional means for disseminating research and increasing support for research. “It’s an evolving collaborative, happening as we speak.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

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Breakfast in Bed, Anyone?

What do beds and pancakes have in common?

Nothin' says lovin' like dust mites from from the... frying pan? Photo by Flickr Creative Commons user Kalavinka

A: Romantic interlude

B: Snuggly Sunday treat

C: Wonderfully considerate partner

D: Potentially lethal mites

Answer:  All of the above

If you’re lucky in love, you get some romance along with your hot pancakes, propped up on your comfy mattress and fluffy pillows.

If you’re not so lucky, you suck in a lungful of Dermatophagoides pteronyssinus from your comforter and slug down a syrup-coated helping of its wheat-loving cousin, Dermatophagoides farina. And if your immune system is easily triggered, this relaxed repast can turn into a choking, wheezing trip to the hospital.

The tiny (300 micron), translucent house dust mite frequently haunts human beds, thoughtfully cleaning up mold, fungi, bacteria, pollen, your dead skin cells, and maybe that other white sock you lost a couple months ago.

Dermatophagoides pteronyssinus - a species of house dust mite. Photo by Flickr Creative Commons user Giles San Martin

Because of their tiny size and adaptive nature, these guys traveled with us from our damp, dark caveman homes to our modern hang outs and creature comforts:  beds, blankets, sofas, rugs, and cuddly stuffed animals.

For most of us, house dust mites cause no problem. They’re so tiny we can’t see them. They don’t sting or bite. And even if 100 were creeping up your leg – which they will probably do tonight – you would never know.

But unfortunately, they can seriously bug people with atopy. It’s not the mite per se, but its numerous droppings that cause issues among the allergic.  Inside those tiny poo balls are bits of undigested food and the digestive enzymes meant to break them down. All it takes is a breath of air – or a dip in pancake batter – for the “stuff” to melt away,  activating these enzymes.

Inhalation reactions start when the molecules come into contact with lung epithelium. Scavenger cells get the inflammatory process up and running, aggravating asthma and other allergic reactions, like atopic dermatitis, allergic rhinitis, conjunctivitis, and otitis media.

Pancake syndrome is a variation of the inhalation reaction. Whenever cooks use mite-infested flour, there is potential for danger. The medical literature contains case reports and series of both children and adults who experienced an anaphylactic reaction after eating mite-infested wheat-flour based foods. The reactions varied from mild to lethal.

In all cases, the flour used was replete with dust mites of several species – and full of the cell-destroying Der enzyme, cysteine protease. Among its many talents: direct damage to airway epithelium; destruction of the body’s epithelial tissue damage defense system; disruption of intercellular junctions; and of course, stimulating those pesky proinflammatory mediators.

Infested flour is more likely to be found in temperate, humid areas, and in poorly stored wheat flour or flour-based mixes – or products that have been opened for a long period and never used. In 2009, the World Allergy Organization published a dust mite oral anaphylaxis paper, suggesting that all grain flours be stored in airtight containers in the refrigerator or freezer.

So the next time a half-empty box of pancake mix gets you in the mood for some snuggly breakfast in bed – try switching to eggs. – Michele G. Sullivan

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Pediatricians Lead the Way in Asthma Care

Busy physicians know that they can only do so much individually. Some health care problems are systemic issues. It takes a lot of people working together to tackle those. It takes a village, if you will.

Dr. Peterson (Photo by Sherry Boschert)

Individual pediatricians have been leading the way in developing some very encouraging collaborative, community-based programs to bolster “medical homes” for children, and especially to improve asthma care. Dr. Tom Peterson has championed one such project in Grand Rapids, Mich. It has brought more financial resources to physicians while decreasing children’s emergency visits by 12% and reducing hospitalizations by 14%. It’s been so successful that other counties in Michigan are copying it. See my full story for more.

Dr. Peterson modeled the Children’s Healthcare Access Program in Grand Rapids after a similar program that was started at Denver Children’s Hospital. He told me that in all the initiatives like this that he’s aware of, the effort starts with the actions of a single pediatrician who gets the ball rolling.

It takes a village, but it starts with individuals. Hats off to the docs who find time to take care of patients and to address the systemic needs. 

—Sherry Boschert (On Twitter @sherryboschert)

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Good News on Inhaled Corticosteroids in Children

Two new studies provide some comfort for physicians and parents who worry about the potential side effects in children from using inhaled corticosteroids for wheezing or asthma. 

Dr. Pederson (Photo by Sherry Boschert)

One long-term Danish study (the Scandinavians excel at longitudinal studies) found no bad eye effects, which previous less-rigorous studies had hinted at. Dr. Søren Pederson of the University of Southern Denmark and his associates followed 148 children using daily inhaled budesonide for chronic asthma from childhood into adulthood. They compared eye exam results in these patients 15-20 years after they began therapy to exam results in 53 of their siblings who did not have asthma and didn’t use budesonide. The ophthalmologist who evaluated all exam results did not know which exams came from the asthmatic kids and which came from healthy siblings.

They found that long-term daily budesonide use didn’t cause more cataracts or significantly change intraocular pressure or vision, Dr. Pederson reported at the annual meeting of the American Academy of Allergy, Asthma and Immunology. AstraZeneca, which markets budesonide, funded the study. The investigators said they had no other potential conflicts of interest.

A separate study validated an alternative to daily inhaled corticosteroids in wheezing toddlers. Clinicians and parents worry about this recommended treatment strategy, because previous studies have shown that daily inhaled corticosteroids have a small but statistically significant class effect of reducing growth in preschool-aged children that only partially reverses if the corticosteroids are stopped, Dr. Leonard B. Bacharier said.

Dr. Bacharier (Photo by Sherry Boschert)

The multicenter, randomized, double-blind, placebo-controlled trial compared the recommended regimen for wheezing toddlers – daily low-dose budesonide – with an alternative regimen, intermittent high-dose budesonide. The intermittent budesonide group got daily placebo and received a 7-day course of high-dose budesonide only when they developed a respiratory tract illness.

Both treatment regimens proved effective, but the daily budesonide group was exposed to more than three times the cumulative amount of inhaled corticosteroid over a year’s time, compared with the intermittent group, Dr. Bacharier of Washington University and his associates reported. Read more in the full story.

Studies like these should help those who care for children with asthma breathe a little easier.

–Sherry Boschert (on Twitter @SherryBoschert)

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Promising Technology Might Help Identify Asthma Earlier

It’s not ready for prime time, but a radiation-free MRI technique could eventually be used to predict which high-risk children will develop asthma, based on data presented by Dr. Daniel Jackson at a press conference at the annual meeting of the American Academy of Allergy, Asthma, and Immunology, in San Francisco.

courtesy of flickr user kquedquest (creative commons)

MRI has been used to assess lung function in adults, but Dr. Daniel Jackson and his colleagues at the University of Wisconsin, Madison, hypothesized that they could obtain similar lung function data from children that could be used to predict asthma risk.

Using a technique developed by study co-author Sean Fain, Ph.D., 43 children aged 9-11 years underwent MRIs after inhaling hyperpolarized helium. The children were selected from the Childhood Origins of Asthma (COAST) project, a long-term observational study of a birth cohort of children at increased risk for asthma.

Using the technique, “we were able to look at the architecture of the lungs,” Dr. Jackson said at the press conference, as areas of the lungs that are not well-ventilated appear black on the MRI. The children’s lungs were assigned defect scores based on the MRI observations.

Children who already had asthma were significantly more likely to have defects than those who didn’t have asthma. But the more interesting finding was that girls were significantly more likely to have higher defect scores compared to boys, whether or not they had asthma.

What does this mean for disease expression? Dr. Jackson said that the next steps call for imaging the children again at age 12-13 years. Although the helium imaging technology is not ready for diagnostic use, it might serve as a biomarker for girls in particular who are at risk for developing persistent asthma after puberty, Dr. Jackson said.

For an excerpt from Dr. Jackson’s comments at the press conference,  click below.

–Heidi Splete (on twitter @hsplete)

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Exposure to BPA During Childhood Linked to Wheeze, Asthma

Exposure to bisphenol-A during childhood is associated with an increased risk of wheeze and asthma in children, results from a novel study demonstrated.

However, during a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology in San Francisco, lead investigator Dr. Kathleen M. Donohue emphasized the preliminary nature of the findings.

Dr. Kathleen Donohue

“There’s nothing about this that’s going to change clinical practice with regard to asthma prevention,” said Dr. Donohue of Columbia University, New York. “I don’t think the data are strong enough yet. It needs to be replicated in other cohorts [and] the possible mechanisms of action need to be better understood.”

Mouse studies have shown that prenatal exposure to bisphenol-A (BPA), an endocrine disruptor widely used in plastic baby bottles and other food containers, is associated with airway inflammation. Dr. Donohue and her associates hypothesized that exposure to BPA would be associated with increased odds of wheeze and asthma during childhood.

To investigate their hunch, they enrolled 400 pregnant women for a prospective birth cohort study. They collected spot urine samples and used mass spectrometry to analyze total urinary BPA level at child ages 3, 5, and 7 years. Board-certified allergists examined the children to determine their asthma status.

Nearly half of the children (47%) were male, 59% were Dominican and 41% were African American. The researchers found that BPA levels at ages 3 and 7 years was associated with increased odds of asthma (odds ratio 1.34 and 1.38, respectively). They also found that urinary BPA level at age 3 was associated with increased odds of wheeze at age 7 years (OR 1.34).

While the potential mechanisms of action remain unclear, Dr. Donohue said that preliminary animal studies suggest that T regulatory cell pathways and Th2 cell pathways can be impacted by exposure to BPA.

“Those pathways are important in terms of asthma development, so we hypothesize that perhaps the BPA was acting through either T regulatory cells or Th2 cytokines to induce asthma and wheeze,” she said.

Stay tuned.

— Doug Brunk (on Twitter@dougbrunk)

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Inner-city Teens Get Asthma Messages by MP3

Ask a teenager what he or she did today, and you’ll probably get the universal adolescent answer: “Nothing.” Turns out that a whole lot of that “nothing” involves using electronic media. Some innovative pilot studies tapped into those habits to get inner-city teenagers to improve their use of asthma medications, Dr. Giselle Mosnaim reported at the annual meeting of the American Academy of Allergy, Asthma and Immunology (AAAAI).

Image of iPod Shuffle by flickr user aliciat80 (Creative Commons license).

She became frustrated when she kept seeing the same teens in the emergency department in acute asthma crisis over and over again. The messages to use their asthma medications were not getting through to them, so she looked for potentially better ways to reach them.

In a large survey study by the Kaiser Family Foundation, youths aged 8-18 years reported that their use of media (TV, music, computer, video games, print, or movies) in 2009 increased to 10 hours and 45 minutes per day, up from 8.5 hours in 2004 and 7.5 hours in 1999. How is that even possible? They’re multitasking 29% of that time, compared with 26% of media time spent multitasking in 2004 and 16% in 1999. Even accounting for multitasking, they were exposed to media 7 hours and 38 minutes per day in 2009.

In that same time span, cellphone ownership increased in this age group from 39% to 66%. The proportion that owned an iPod or other MP3 player increased from 18% to 76%.

Dr. Mosnaim (Photo by Sherry Boschert)

So Dr. Mosnaim designed a pilot study in which 27 inner-city teenagers with asthma received free cellphones and could choose music to listen to via the phones, but they had to  hear messages from celebrities urging them to take their asthma meds before they could access the music. That study bombed. (Not as in, “You’re the bomb!” but as in, “Fail!”)  Medication adherence did not improve, and the teens found a way around safeguards on the cellphones to run up hundreds of dollars in calls that they weren’t supposed to be making, said Dr. Mosnaim of Rush University Medical Center, Chicago. Plus, they didn’t think much of the celebrity messages.

So she tried again, this time using iPod Shuffles. Four teens in the second pilot study were allowed to download 10 profanity-free MP3 songs per week. They met weekly in coping/peer-support groups, where they recorded their own take-your-asthma-meds messages, and those were mixed in with the tracks on the iPod Shuffle. I don’t have permission to post audio of some of those messages here, but suffice it to say that their creativity outshines most rappers and DJs. The investigators attached a device to each teen’s inhaler to objectively measure medication adherence.

Hearing their own voice on the “asthma track” proved to be a hit. And it seemed to work. Medication adherence increased to 70% in 8 weeks, a “clinically significant treatment target,” Dr. Hosnaim said.

The idea is now graduating from pilot studies to a randomized, controlled trial with 90 participants. The control group will get the iPod Shuffles and follow the same protocol as the intervention group, but the voice on the asthma messages will be Dr. Mosnaim.

Not too long ago, I might have ended this blog post by saying, “Stay tuned.” That’s so last century. When the study’s results drop, you’ll get them here first. Are you subscribed?

– Sherry Boschert (@SherryBoschert on Twitter)

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