Journals

Most Epi & Inhaler Users Do It Wrong A study in the upcoming issue of the Annals of Allergy, Asthma, and Immunology by Texas researchers finds just 16% of epi users are administering the medication correctly, with most not holding the injector in place long enough. With inhalers, only 7 percent of users demonstrated perfect technique and 63 percent missed three or more steps. The most common misstep was not exhaling as much as possible before using the inhaler. More

Clinical reactivity to hazelnut may be better identified by component testing than traditional testing methods Researchers at the Jaffe Food Allergy Institute at Mount Sinai report that component testing may be more effective than allergen-specific IgE (RAST) and skin-prick testing for diagnosing hazelnut allergies. As with peanut, there is overlap with birch pollen allergy. More

Overweight Children Mistakenly Attribute Breathing Problems to Asthma, Leading to Overuse of Medicines, Inactivity Researchers in Florida and Delaware report “Overweight/obese children with early-onset asthma display poorer asthma control and a distinct pattern of symptoms. Greater shortness of breath and ?-agonist use appears to be partially mediated via esophageal reflux symptoms. Overweight children with asthma may falsely attribute exertional dyspnea and esophageal reflux to asthma, leading to excess rescue medication use.” More

Link Between Dry Roasting and Allergy for Peanuts Confirmed in Mice The prevalence of peanut allergy in the United States compared to East Asian countries that have comparable levels of peanut consumption has been attributed to the preference of Americans for dry roasting as the primary means of cooking, compared to boiling, pickling, frying, and leaving them raw. Researchers at Oxford and the University of Pennsylvania have now confirmed this by priming “mice subcutaneously with endotoxin-depleted soluble fractions of peanut protein extract (PPE) from raw or [dry roasted] peanuts in PBS without adjuvant…” “Subsequent intragastric gavage and whole peanut feeding elicited higher peanut-specific IgG and IgE titers in the DR compared with raw PPE–sensitized mice. Moreover, DR PPE–sensitized mice had higher eosinophilic infiltration of the lamina propria and increased IL-4, IL-5, and IL-13 secretion by mesenteric lymph node cells. Taken together, these data consolidate an enhanced TH2/allergenic profile of DR compared with raw peanuts that was maintained across the subcutaneous, epicutaneous, and gastrointestinal routes of sensitization.” More

Internet Searches on Allergies Shoot Up During Pollen Season The Annals of Allergy, Asthma, and Immunology reports, “The exacerbation of allergies has been shown to directly correlate with seasonal elevations in aeroallergens as reported with pollen counts. Google and similar search engines increasingly serve as primary sources of medical information for the public. Approximately 72% of Internet users seek health-related information on the Internet, with 77% using search engines. Google searches account for approximately 67%.”

Poor Kids with Asthma Suffer Permanent Behavior Problems
(Science Daily) A researcher at the University of Missouri-Columbia has done the first large-scale study of overall outcomes of socio economic inequalities for children with asthma.”As with all chronic illnesses, there is a biological mechanism behind asthma, but asthmatic children’s prognoses depend heavily on parental management, and successful management often relies on social circumstances,” said Jen-Hao Chen, an assistant professor in the MU School of Health Professions. “My research indicated that there is a profound socioeconomic difference in these outcomes, with the poor consequences of asthma concentrated among children from economically disadvantaged backgrounds.” Chen’s study used data from the Early Childhood Longitudinal Study-Birth Cohort, which includes 5,750 children in the United States and documents changes in their behavioral skills during important developmental periods in early childhood. Chen looked at behavioral measures affected by asthma, including attention levels, social skills and aggressiveness, and found that — although all asthmatic children are at risk for difficulties in these areas — the negative consequences disappeared for children who had never experienced poverty and had highly educated parents.
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Early Antibiotic Use Correlated with Asthma Only if Used for Respiratory Infections, Study Finds In a letter to the Journal of Allergy and Clinical Immunology, a number of researchers mostly from the University of Chicago found that early use of antibiotics was often associated with later development of asthma symptoms, but not for all kinds of infections. Non-respiratory use didn’t correlate with the development of wheezing and other symptoms.

“Our results indicate that the association between antibiotic use and subsequent asthma holds only in the case of respiratory infections, adding to the previous research suggesting that the relationship may be explained by reverse causation or confounding by indication. There are some limitations with our study, however. Asthma is a complex clinical disease that is difficult to assess before age 6 years. Given that our study included diagnoses before age 3 years, the nature of the disease progression may still be unpredictable. Because there was a high rate of infections in this cohort, there may be a covariation effect between infections and antibiotic use that we were unable to separate. Also, the use of antibiotics and type of infections noted are based on parental recall and so are prone to recall bias. Another limitation is that we do not have access to the types of antibiotics used. Broad-spectrum antibiotics became more prevalent in the 1980s and may alter the microbiome more than the narrow-spectrum antibiotics used in the past.

“Despite the limitations inherent in this research, we conclude that the associations found between antibiotic use in young children and the subsequent development of asthma and wheezing may be due to confounding by respiratory infections.” Brittany Lapin MPH, et al
Notably, the research only dealt with asthma, not food allergies or other immune disorders that have been associated with damage to the microbiome from antibiotics.
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Basophil Activation Test Greatly Reduces Need for Food Challenges in Suspected Cases of Peanut Allergy A Team of British researchers has found that basophil activation tests can effectively distinguish between peanut sensitivity and tolerance for cases in which other tests produced equivocal results. Basophils, effector cells that circulate in the blood, are easier to harvest than mast cells, which are lodged in the skin and other organs. When extracted from the blood and exposed to an allergen like peanut proteins, they will degranulate, indicating what would happen in the body only without any risk to the patient. Big drawback? Expensive.
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Five-Year Follow Up Show No Omalizumab (Xolair) Link to Increased Cancer
When Xolair was first introduced as a treatment for hard-to-control asthma, alarms were raised about a small statistical correlation with malignancies. A new study by Aidan Lon, MD et al published in the Journal of Allergy and Clinical Immunology is described this way: “Epidemiologic Study of Xolair (omalizumab): Evaluating Clinical Effectiveness and Long-term Safety in Patients with Moderate-to-Severe Asthma (EXCELS) was initiated as a postmarketing commitment to the US Food and Drug Administration to assess the long-term safety of omalizumab and provided the opportunity to evaluate malignancy rates in clinical practice. Interim data from EXCELS have been published previously.”

Omalizumab is an “anti-IgE” drug that keeps allergens from attaching to mast cells and basophils, which has been studied as an adjunct to oral immunotherapy (OIT) for desensitizing food allergy patients. “In conclusion, the results from EXCELS suggest that omalizumab is not associated with an increased risk of malignancy. The results from multiple exploratory and sensitivity analyses, expected rates in the general population, and limited evidence of biologic plausibility support this conclusion.”
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Clinical features and resolution of food protein–induced enterocolitis syndrome: 10-year experience
Caubet, et al
This study from Mount Sinai shows that while most FPIES resolves by age five, those with milk and soy FPIES and those with food-specific IgE take longer to resolve
“…FPIES is an underrecognized non–IgE-mediated food allergy that most commonly affects infants and is usually caused by cow’s milk, soy, rice, and oat. Early recognition of the symptoms of FPIES and removal of the offending food are imperative to prevent misdiagnosis and mismanagement of symptoms that might mimic viral illness or sepsis and lead to failure to thrive when food is chronically present in the diet. Our data suggest that introduction of milk formula, soy formula, or both within the first weeks of life is an important risk factor for the development of FPIES to milk, soy, or both. The diagnosis of FPIES is based on clinical criteria that should not include an age restriction because FPIES can occur at any age. Although a physician-supervised OFC remains the gold standard for diagnosis of FPIES, diagnostic criteria for a positive OFC result might need to be modified to remove diarrhea and stool studies as major positive criteria because diarrhea is relatively uncommon during an OFC in older children. Close follow-up is required to determine when foods might be added back into the diet. Although solid food FPIES resolves in most subjects by 5 years of age, subjects with milk and soy FPIES, as well as those with detectable food-specific IgE, might have a more protracted course. Further studies are needed to determine the pathophysiology and biomarkers of FPIES, as well as the features of natural history that are unique for specific foods.”
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New Evidence of Association Between Microbiome and Eosinophilic Esophagitis A letter in In Practice, the companion journal to JACI from major researcher finds “Birth by cesarean section and early antibiotic use were found to be associated with eosinophilic esophagitis in young children, which suggests that altered microbiota many play a role in this disease.” More.

Allergic sensitization is a key risk factor for but not synonymous with allergic disease
Johns Hopkins researcher Robert Hamilton, PhD writes, “Although it is a key risk factor for allergic disease, allergic sensitization is not synonymous with allergic disease without the presence of a positive clinical history. Although a questionnaire-based history was collected from subjects participating in the NHANES 2005-2006 study,2 no clinical history data were considered in the current report. Thus the authors correctly make no attempt to translate their reported ‘IgE sensitization prevalence rates’ into regional trends of ‘allergic disease’ among the American population. The reader is encouraged do the same and not make this leap between IgE sensitization and allergic disease. Thus the 36.2% of 1- to 5-year-olds and 44.6% of subjects greater than 6 years of age who are identified as sensitized by having circulating IgE antibodies to at least 1 allergen specificity will most certainly be an overestimate of the actual prevalence of actual allergic disease in the United States. Balancing this is the possibility that some sensitized subjects in the study cohort were not identified because of the practical necessity of limiting the number of allergen specificities tested with the available blood.” More

Diesel exhaust particle exposure during pregnancy promotes development of asthma and atopy
Fred D. Finkelman, MD
“Environmental effects strongly influence the development of atopic diseases, including asthma. The importance of these effects does not appear to be evenly distributed throughout life; instead, effects that occur during the first year of life and especially during the neonatal period appear to be particularly important. Relatively recently, evidence has accumulated that even the intrauterine environment can strongly influence the later development of atopy and asthma. In addition to evidence that the development of atopy in the child correlates more strongly with the presence of maternal than paternal atopy, epidemiologic studies have suggested that maternal cigarette smoking and exposure to diesel exhaust and traffic-related particles, heavy metals, antibiotics, alcohol, and house dust mites can increase the child’s risk of atopy, asthma, or both, whereas maternal pet exposure and exposure to farm animals and the buildings that house them can have the opposite effect.” More

British Researchers Show Huge Boom in Allergy Products on eBay “[T]he number of allergy-related products available on eBay.co.uk increased 17-fold between 2007 and 2012. This is probably mirrored in other Internet marketplaces…Most of these products aim to reduce exposure to allergens (either home products or hypoallergenic items, such as jewelry). Across the board there is a trend for more products being traded for allergic conditions in children. Although the overall number within each category has increased, there has been relative growth in hypoallergenic items and books—not just clinical textbooks but also books providing cookery and patient information, suggesting that people are trying to manage their allergies and educate themselves about their condition.” More

Food Challenge Effect on Quality of Life A European study found that patients reported better quality of life [QOL] immediately after challenges, whether they were positive or negative. However, while QOL continued to improve for those found not to have allergies, it started to decline for those who did after several months. More.

Large Numbers of People Who Have Outgrown IgE-Mediated Food Allergies Later Experience EoE to Same Foods Dr. Scott Sicherer discusses an upcoming article about it with the author, Dr. Jonathan Spergel in a JACI video. To watch it click here.

Anaphylaxis as an Occupational Risk “Allergens derived from Hymenoptera and natural rubber latex are the most frequently reported triggers of OcAn, but other high and low-molecular weight agents have been described. Among the latter, foods, insects, snakes, chemicals, and medications have been described in the last 2 years. Furthermore, reviews on the clinical significance of immunological contact urticaria as a risk factor for systemic allergic reaction and on Hymenoptera venom immunotherapy have been published.” More

Little Evidence for Dietary Supplementation to Mitigate Allergies, Asthma

Effects of antioxidant supplements and nutrients on patients with asthma and allergies
Hortensia Moreno-Macias, LA, MSc, ScD, Isabelle Romieu, MD, MPH, ScD
The Journal of Allergy and Clinical Immunology
Volume 133, Issue 5 , Pages 1237-1244, May 2014

Concepts and therapeutic implications
•Dietary or vitamin supplementation with antioxidants (a broad and varied category) has been proposed as an approach to reducing asthma incidence or morbidity.
•Meta-analyses of observational epidemiologic studies of variable methodological quality suggest associations of relatively low dietary intake of antioxidants and higher asthma and allergy prevalence.
•The origins of asthma and allergy might be in fetal life or early childhood, but there have been few longitudinal observational studies of maternal or early childhood dietary or vitamin supplement antioxidant intake and asthma/allergy development.
•Large trials of antioxidant vitamin supplementation to prevent cancer suggest an increase in overall mortality with antioxidant vitamin supplementation, at least in populations with sufficient dietary antioxidant intake. This cautionary experience suggests that future trials to assess whether antioxidants reduce asthma incidence or improve asthma control should focus on supplementation of dietary sources of antioxidants.
•A few small clinical trials suggest that specific antioxidants from diet or vitamin supplements might improve asthma control or lung function in asthmatic children or adults.
•Responses to antioxidants might be modified by life stage, genetic susceptibility, and environmental sources of oxidative stress.
•The potential benefits and risks of trials of vitamin supplements might be considered in special situations in which vulnerable populations have marked deficiency in dietary antioxidants, poor access to dietary antioxidants, or high exposure to environmental sources of oxidants (eg, air pollution).
•As McKeever and Britton stated, “The therapeutic implication of a healthy diet consists in taking advantage of the amount of natural nutrients in particular foods and the combination and interaction among nutrients in different foods. The best way to deliver a suitably comprehensive and synergistic range of nutrients is to supplement the diet with fresh fruits and vegetables.”

Omalizumab (Xolair) for Asthma Not Associated With Higher Cancer Rates “The clinical benefit of omalizumab has been established in several large clinical trials. However, concern regarding a potential association with malignancy risk has led to a need to evaluate further the long-term safety of omalizumab. EXCELS is the first study to evaluate the long-term safety of omalizumab in a large population of patients with moderate-to-severe allergic asthma in a real-world setting. EXCELS had a median follow-up of approximately 5 years for both the omalizumab and nonomalizumab cohorts and included patients at high risk of cancers (smokers and family history of cancer) and patients with a history of malignancy. Analyses of time to first primary malignancy adjusted for potential confounders also demonstrated similar risk between the 2 cohorts. These results suggest that omalizumab is not associated with an increased risk of malignancy, a conclusion also supported by the results of the sensitivity analyses. In addition, although patient numbers in subgroup analyses of subjects with a personal history of cancer/premalignant condition and patients with active cancer at baseline were small, the results suggest that omalizumab is not associated with a risk of malignancy progression. An exploratory analysis of cumulative omalizumab exposure on malignancy risk showed no meaningfully increased risk of malignancy.” {Note: this study concerns long-term use of Xolair, not as a short-term adjunct to oral immunotherapy for food allergies.}
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Chronic urticaria not related to food additives Researchers “challenged 100 patients in our allergy/immunology division with CIU to the 11 additives most commonly associated with reactions: tartrazine (FD&C Yellow 5), potassium metabisulfite, monosodium glutamate, aspartame, sodium benzoate, methyl paraben, butylated hydroxy anisole, butylated hydroxy toluene, FD&C Yellow 6, sodium nitrate, sodium nitrite. All of the patients had a history of CIU for longer than 6 weeks, and 43 reported possible history of food or drug additive sensitivity. Single-blind challenges to all of the additives were performed in the clinic and skin scores were recorded. Subjects with positive challenge tests underwent double-blind placebo controlled challenges.

Results
Of 100 subjects, only 2 had a positive urticarial response on single-blind challenge. Neither of these patients had a positive urticarial response on double-blind placebo-controlled challenge. There were no gastrointestinal, respiratory, or other symptom, and no patients reported late reactions.

Conclusion
We were able to conclude, with 95% confidence intervals that sensitivity to any of the 11 food and drug additives occurs in fewer than 1% of patients with CIU. Food and drug additives appear to be a rare cause of CIU, and avoidance is not recommended.” More

The decline of US research and development expenditures
“The National Institutes of Health has always been the major contributor to US biomedical research and development, maintaining global dominance in research dollars spent. However, cuts mandated by the Budget Control Act of 2011 have reduced spending by 5.5% in 2013, continuing a trend of decreasing federal funding for biomedical research since 2003. Chakma et al (N Engl J Med 2014;370:1) examined global biomedical research expenditures by the public sector and private industry in the United States, Canada, Europe, and the Asia-Pacific region since 2007. The authors explain that expenditures increased only in Asia-Oceania by $15.1 billion, whereas a reduction in spending was seen in the United States, Europe, and Canada by more than $15 billion. This decrease in spending is primarily due to a $12.9 billion reduction in US industry’s investment in research and development. Although funding from the US public sector did not decrease, sequestration of National Institutes of Health funding in 2013 and beyond will cause it to decrease as well, which will exacerbate the overall US reduction in research spending. Taken together, there is increasing concern about the United States losing its leading global position in the medical research field.” –Journal of Allergy and Clinical Immunology, March 2014

Risk Factors for Food Allergies Why does one person become food allergic and another (including siblings and even twins) not allergic? In a JACI article called “Food allergy: Epidemiology, pathogenesis, diagnosis, and treatment” Drs. Hugh Sampson and Scott Sicherer summarize the risk factors this way: “A plethora of risk factors are proposed to influence food allergy or sensitization, including sex (male sex in children), race/ethnicity (increased among Asian and black children compared with white children), genetics (familial associations, HLA, and specific genes), atopy (comorbid atopic dermatitis [AD]), vitamin D insufficiency, dietary fat (reduced consumption of omega-3-polyunsaturated fatty acids), reduced consumption of antioxidants, increased use of antacids (reducing digestion of allergens), obesity (being an inflammatory state),28 increased hygiene, and the timing and route of exposure to foods (increased risk for delaying allergens with possible environmental sensitization).” Read more here.

Private Practice Oral Immunotherapy (OIT) for Food Allergies—the controversy continues In Practice, companion journal to the Journal of Allergy and Clinical Immunology published articles on both sides of the divide. The first, “Oral Immunotherapy for Peanut Allergy: Multipractice Experience With Epinephrine-treated Reactions” by Wasserman, et al, “reports a retrospective medical record review of patients who received POIT (peanut oit) treatment through July 1, 2012, in 5 allergy practices.” The different practices did not use the same protocols.

“Results
A total of 352 treated patients received 240,351 doses of peanut, peanut butter, or peanut flour, and experienced 95 reactions that were treated with epinephrine. Only 3 patients received 2 doses of epinephrine, and no patient required more intensive treatment. A total of 298 patients achieved the target maintenance dose for a success rate of 85%.
“Conclusion
Peanut oral immunotherapy carries a risk of systemic reactions. In the context of oral immunotherapy, those reactions were recognized and treated promptly. Peanut oral immunotherapy may be a suitable therapy for patients managed by qualified allergists/immunologists.”

The article was critiqued by Wood and Sampson in “Oral Immunotherapy for the Treatment of Peanut Allergy: Is It Ready for Prime Time?
They assert:
“Their report emerges with 2 main messages. First is that they had a success rate of 85% based on the number of patients who reached the targeted maintenance dose and, second, that reactions to dosing that required epinephrine were relatively uncommon, which occurred in 0.7 of 1000 doses during dose escalation and in 0.2 of 1000 doses during maintenance. With regard to these outcomes, we believe that it is important to consider several additional perspectives. Although achieving maintenance is a reasonable outcome, it is important to note that this, in fact, could range among the sites from 415 to 8000 mg of peanut protein. Given this enormous range, with approximately one-third of the results based on the lowest maintenance dose, it is very difficult to understand what this outcome really means and hard to justify it as a definition of success. It would be far preferable to have a well-defined outcome, such as a challenge threshold before and after treatment, although we recognize that this may not be possible in practice settings. In addition, they report that an additional 5% of patients dropped out while on maintenance and, far more importantly, that the maintenance period only lasted for ‘a few weeks’ in some patients.
“The second outcome, based on the rate of reactions that required epinephrine, is also problematic. The investigators do provide an estimate that compared their rate of epinephrine use with epinephrine use in untreated patients and state that treated patients have an approximately 2-fold increased chance of a reaction that requires epinephrine compared with untreated patients. This outcome would likely be acceptable if the treatment resulted in a significant long-term reduction in reactions from accidental exposures. However, such long-term results are currently unknown. In addition, their assessment of this risk was based on data from a single study that may not accurately represent the true risk of anaphylaxis in patients with untreated peanut allergy. Although the study that they quoted reported a risk of accidental peanut reactions as occurring in 11.9% of patients each year, in fact, only 20% of those reactions were treated with epinephrine. Furthermore, this rate of reaction is far higher than that of a recent large US study that reported a rate of accidental exposures with severe reactions of 1.6% per year and of reactions treated with epinephrine of 1.1% per year. Based on our review of all available data, as well as our cumulative clinical experience, we estimate that the risk of reactions of all types, including severe anaphylaxis, is far higher in patients being treated with OIT than in patients who practice avoidance.”

Both articles can be found in The Journal of Allergy and Clinical Immunology: In Practice Volume 2, Issue 1 , Pages 91-98, January 2014

Allergy to uncommon pets: new allergies but the same allergens
Araceli Diaz-Perales, David González-de-Olano, Marina Perez-Gordo, and CARLOS PASTOR-VARGAS
The prevalence of exotic pet allergies has been increasing over the last decade. Years ago, the main allergy-causing domestic animals were dogs and cats, although nowadays there is an increasing number of allergic diseases related to insects, rodents, amphibians, fish, and birds, among others. The current socio-economic situation, in which more and more people have to live in small apartments, might be related to this tendency. The main allergic symptoms related to exotic pets are the same as those described for dog and cat allergy: respiratory symptoms. Animal allergens are therefore, important sensitizing agents and an important risk factor for asthma. There are 3 main protein families implicated in these allergies, which are the lipocalin superfamily, serum albumin family, and secretoglobin superfamily. Detailed knowledge of the characteristics of allergens is crucial to improvement treatment of uncommon-pet allergies.
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Pilot study of Xolair + OIT in high-risk peanut-allergic patients shows promise
Lynda C. Schneider, MD, Rima Rachid, MD, Jennifer LeBovidge, PhD, Emily Blood, PhD, Mudita Mittal, MD, Dale T. Umetsu, MD, PhD
The Journal of Allergy and Clinical Immunology
Volume 132, Issue 6 , Pages 1368-1374, December 2013

Thirteen children (median age, 10 years), with a history of significant allergic reactions to peanut, and high IgE levels, who also failed an initial double-blind placebo-controlled food challenge at peanut flour doses of 100 mg or less, were pretreated with omalizumab Xolair and given rush oral immunotherapy. Twelve subjects reached the maximum maintenance dose of 4000 mg peanut flour per day in a median time of 8 weeks, and omalizumab was discontinued. All 12 subjects continued on 4000 mg peanut flour per day and subsequently tolerated a challenge with 8000 mg peanut flour (equivalent to about 20 peanuts), 160 to 400 times the dose they could tolerate previously. Six subjects experienced mild or no allergic reactions, 5 had grade 2 reactions, and 2 had grade 3 reactions, all of which responded rapidly to treatment.

“In conclusion, our study suggests that omalizumab may facilitate rapid oral desensitization in high-risk peanut-allergic patients with high peanut-specific IgE levels. All the patients tolerated a cumulative dose of 992 mg peanut flour on the first day of desensitization, and 92% were able to rapidly tolerate doses of 8000 mg peanut flour. Although we cannot yet recommend omalizumab to facilitate oral desensitization, our results provide strong evidence that omalizumab can effectively reduce allergic reactions and expedite successful and rapid oral peanut desensitization in patients with high peanut-specific IgE levels. Larger randomized placebo-controlled studies are currently being conducted to confirm a beneficial role of omalizumab in facilitating oral peanut desensitization.”

New Study Shows Just 30% of Food-Allergic Kids Have Current Epi Prescription A new study presented at the ACAAI meeting in Baltimore recently showed that only 30% of food-allergic children presenting to a pediatric outpatient clinic have current prescriptions for epinephrine autoinjectors, and far fewer have chart documentation of how to use it.

“It was a surprise,” lead investigator Christopher Couch, MD, told Medscape Medical News before presenting the findings. Ronna Campbell, MD, from the Mayo Clinic Department of Emergency Medicine, wrote in a 2012 review article (Pediatr Emerg Care 2012;28:938-942), “In a study of junior and senior medical staff demonstrating the use of the EpiPen, Mehr et al revealed that, in 37% of cases, the physician’s demonstration would have failed to deliver epinephrine to a patient….Furthermore, 16% of the physicians would have self-injected their thumb had they been using an actual EpiPen.”

Killing Eosinophils? New Approach to Allergies Suggested by Israeli Research
As reported in Science Daily, elevated eosinophil levels are associated with certain allergic reactions, including asthma, as well as gastrointestinal diseases, blood disorders, and cancers.
A study published in Nature Immunology (November), led by Dr. Ariel Munitz of the Department of Clinical Microbiology and Immunology at the Sackler School of Medicine at Tel Aviv University, and conducted by graduate students Netali Baruch Morgenstern and Dana Shik, “has found a mechanism that pushes eosinophils to die before they get into the blood and wreak havoc. The discovery is a breakthrough in science’s understanding of the immune system and suggests powerful new treatments for eosinophilic diseases…”

“We’ve discovered an important and powerful pathway that works to kill eosinophils,” says Dr. Munitz.

Science Daily goes on “Analyzing the bone marrow of mice, the researchers found that the expansion of eosinophils caused by IL-5 is actually part of a broader mechanism that regulates the lifecycle of the cells. While IL-5 commands eosinophils to expand and enter the bloodstream, a cell receptor called paired immunoglobulin-like receptor A, or PIR-¬A, commands eosinophils to die. So eosinophils are in a constant ‘tug-of-war’ between survival signals delivered by IL-5 and death orders delivered by PIR-A.”
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Round-up of Studies from American College of Allergy, Asthma & Immunology
From Science Daily

Insect stings send more than 500,000 Americans to hospital emergency rooms and cause at least 50 known deaths each year. A person who has had an allergic reaction to insect sting has a 60 percent chance of having another similar or worse reaction if stung again. Immunotherapy has been shown to be an astonishing 97 percent effective in preventing future allergy to insect stings.”
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Blanket food avoidance too drastic for some food-allergy patients. Dr. Sammy Bahna says, “While many food allergic individuals find they can eat certain parts of food or substitutes, this isn’t a one size fits all approach. Allergy manifests in everyone differently. If you have a food allergy, evaluation by a board-certified allergist can identify the exact foods that you should avoid and the substitute foods that you can safely eat.” More

Bone marrow transplant cures peanut allergy. Boy diagnosed with peanut allergy at 15 months “underwent a bone marrow transplant for leukemia, from a donor with no known allergies. Soon after, the child seemed to no longer have an allergy to peanuts. Allergists confirmed with an oral food challenge, which should only be done in an allergist’s office, where the child ate a small amount of peanut and showed no allergic reaction.” {*Bone marrow transplants cost estimated $800,000, plus maintenance, and involve dangerous destruction of immune system prior to procedure.) More.

Simple measures like dose-metered inhalers can cut asthma emergencies substantially. Also, board certified allergists result in 54 to 76 percent reduction in emergency room visits, 60 to 89 percent reduction in hospitalizations, 77 percent reduction in lost time from work or school. More.

Oral allergy syndrome can escalate to anaphylaxis when combined with high blood pressure medication. “Oral allergy syndrome sufferers that take high blood pressure medications may experience extreme facial swelling and difficulty breathing the next time they bite into a juicy apple. When patients with oral allergy syndrome take angiotensin-converting enzyme (ACE) inhibitors for hypertension and congestive heart failure, they are at an increased risk for a life-threatening allergic reaction known as anaphylaxis, according to new research.” More.

“The holidays can suddenly spur allergy symptoms in people with asthma and those that have never before had allergies. For example, while visiting a relative with cats, a runny nose, sneezing and itchy eyes can occur. Then there is the Thanksgiving Effect, where college students return home to a pet they didn’t have symptoms to before and are now allergic.” More.

Allergy Shots During Pregnancy May Decrease Allergies in Children “Our research found trends suggesting women receiving allergy shots either before or during pregnancy reduced their child’s chances of having asthma, food allergies, or eczema,” said allergist Jay Lieberman, MD, ACAAI member. “Prior studies have suggested that mothers can pass protective factors to their fetus that may decrease their child’s chance of developing allergic disease, and these protective factors are increased with allergy immunotherapy.” More.

Congratulations to AAC Contributors Anne Ellis, MD, and Michelle North, PhD of Queens University in Kingston, Ontario for their new publication in the Annals of Allergy, Asthma, and Immunology on their environmental exposure unit at Queens for the study of airborne allergens. Our readers will recall Anne’s piece on this subject, which you can read here.

Food Allergies More Prevalent Among Kids with GERD Treated with Antacids
Pediatric Allergy and Immunology
Volume 24, Issue 6, pages 582–588, September 2013

Dr. Anita Trikha and colleagues at National Jewish Health studied the medical records of more than 8000 children with gastroesophageal reflux disease (GERD) in all, divided equally between those who were treated with gastric acid suppressive (GAS) drugs and those who were not. They say, “Our results indicate over a twofold increase in the development of food allergy at 1 yr in patients on GAS medications. This is a concern given the increase in use of GAS medications in children, especially when studies demonstrating efficacy are not clear.” They point out that since the data only reflect the population that has been taking these medicines by prescription, and that many more may have been given over-the-counter meds, the figures may be too low. The authors conclude: “This study suggests the need for further evaluation of the role of gastric acid suppression in the development of food allergy as well as highlights the importance of the judicious use of these medications, especially in the pediatric population.”

(The authors cite, among others, the work of Dr. Eva Untersmayr in Vienna, who did a recent piece for us on the association of antacid use and adult-onset food allergies, and who brought this article to our attention.)

New Association of Allergies, C-Section
Allergic Living reports that new research “adds to the growing body of evidence that suggests infants who are born via Caesarian section are more likely to develop allergies later in life.”
The study from Sweden says that babies delivered by Caesarian section had fewer varieties of microbes in the gut in the first two years of age, and lower levels of certain special immune messenger proteins (called chemokines), which help to promote a non-allergic response to allergens.
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Food Allergy Costs Near $25-Billion Annually
Children’s food allergies cost an estimated $24.8 billion each year in the U.S.
Direct costs for in-office, emergency, and other medical care totaled $4.3 billion per year, Ruchi Gupta, MD, MPH, of Northwestern’s Center for Healthcare Studies in Chicago, and colleagues found.
Families paid $5.5 billion per year out of pocket — an average of $931 per child per year — on things such as copays, medications, and special diets or childcare to avoid allergens, the researchers reported online in JAMA Pediatrics. But the biggest portion of the costs, $14.2 billion, came as lost opportunities for the caregivers, including a change or loss of a job.
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Studies Describe Limitations of Long-Term Oral Immunotherapy [OIT] for Cow’s Milk Allergy
The Journal of Allergy and Clinical Immunology
Volume 132, Issue 3 , Pages 737-739.e6, September 2013

A letter in the Journal of Allergy and Clinical Immunology from major researchers, most prominently Dr. Robert Wood, reported follow-up data from two studies of cow’s milk [CM] OIT. Groups were divided into two groups: “those who consumed at least 1 serving of CM daily with no more than oral/pharyngeal symptoms and those who either consumed less CM or reported symptoms.”

“Twenty-two percent reported limiting their consumption because of symptoms, 9% because of anxiety, and 13% because of taste. In addition, 25% limited CM with exercise and 6% with illness. Most reactions were not attributed to cofactors, but 13% reported increased symptoms with exercise, 9% with illness, and 6% after missing several days of CM. Notably, some subjects who initially did well and passed interim OFCs subsequently had increased symptoms and began to restrict CM. Disturbingly, some subjects had significant symptoms after study completion of which we were unaware, with 1 subject reporting using epinephrine at least twice per month for reactions to CM.”

The researchers acknowledged limitations of the study, and called for better design of subsequent studies.

New Study Finds Strong Links Between Gut Microbe Environment and Eczema
The Journal of Allergy and Clinical Immunology
Volume 132, Issue 3 , Pages 601-607.e8, September 2013

A study published by German researchers in the Journal of Allergy and Clinical Immunology seems to strengthen the association between the bacterial environment of infants’ guts and the development of atopic dermatitis. While most children were breast fed, the researchers “found profound differences in the microbiome composition, at the age of 31 weeks, of infants who were breast-fed for >6 months compared with infants who were breast-fed for a shorter period. In the past decades formulas have become supplemented with compounds such as long-chain polyunsaturated fatty acids, oligosaccharides, nucleotides, and lactoferrin to mimic human milk as much as possible. Yet, numerous bioactive compounds in breast milk, including immunoglobulins, cytokines, hormones, enzymes, and microbes, are not present in infant formulas that might contribute to the beneficial effect of breast-feeding on microbiota development.”

They also found a link between caesarian delivery and the infant microbiota. and “confirmed that vaginal-delivered infants acquired bacterial communities resembling their own mothers’ vaginal microbiota. However, infants delivered by C-section harbored bacterial communities that were most similar to those found on the skin surface…. Furthermore, we report for the first time a dose-response relationship between birth order and microbiota composition, which lends further support to a causal relationship.”
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Peanut protein in household dust is related to household peanut consumption and is biologically active UK researchers find
A new article in JACI reports, “Peanut protein was quantified in wipe and dust samples collected from 45 homes with infants by using a polyclonal peanut ELISA. Environmental peanut protein levels were compared with peanut consumption assessed by using a validated peanut food frequency questionnaire and other clinical and household factors. Biological activity of peanut protein in dust was assessed with a basophil activation assay.

“There was a positive correlation between peanut protein levels in the infant’s bed, crib rail, and play area and reported HPC over 1 and 6 months. On multivariate regression analysis, HPC was the most important variable associated with peanut protein levels in the infant’s bed sheet and play area. Dust samples containing high peanut protein levels induced dose-dependent activation of basophils in children with peanut allergy.”
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Japanese Guideline for Adult Asthma
doi:10.2332/allergolint.11-RAI-0327
“According to the Vital Statistics of the Ministry of Health, Labour and Welfare, the number of patients (of all ages) who died from asthma has gradually decreased in recent years. That stopped decreasing at a rate of 4.5-5.0 per 100,000 patients around 1975, transiently increased in 1995, decreased again after 1997, and then hit its lowest point of 1.7 per 100,000 patients (2,139 deaths) in 2009. In particular, the number of patients who died from asthma at an early age markedly decreased, thus, currently 88% of deaths occur among the elderly, aged 65 years or older.”
With almost 128 million people, Japan’s population is less than half that of the United States, with 316 million.  However, Japan’s annual death toll from asthma is higher per capita than the U.S., which is between 3 and 4,000.  Japan’s life expectancy is higher than ours by several years overall.

Oral Immunotherapy for Peanuts Seems to Be More Effective than Sub-Lingual 
A letter in the Journal of Allergy and Clinical Immunology
from various researchers (Stacy J. Chin, MD et al) compares changes in the immune system fromOral Immunotherapy (OIT) for peanut allergy with Sub-Lingual Immunotherapy (SLIT). The letter recounts findings from a “retrospective study of 2 previously published protocols for peanut allergy” with “new analysis [that] includes additional subjects, compares the 12-month oral food challenge outcomes, and extends analysis of immunologic parameters out to 24 months.” Among the measures are the levels of peanut-specific IgE (allergic antibody) and IgG4 (good “blocking” antibody) that compete for space on mast cells and basophils, which when activated, result in an allergic response. The ratios of IgE and IgG4 were also measured.

They summarize their findings, “[O]ur results suggest that after 2 years of treatment, OIT produces greater immunologic changes than SLIT in peanut-allergic children. Specifically, peanut OIT resulted in greater changes in peanut-specific IgE, IgG4, and IgE/IgG4 ratio as well as basophil activation.   In addition, eliciting dose thresholds were lower and more variable during double-blind placebo-controlled food challenges (DBPCFC) at 12 months in SLIT-treated subjects than in OIT-treated subjects. Subjects who passed the DBPCFC tended to have lower baseline peanut-IgE levels, in addition to a larger fold change in peanut-IgG4 and less basophil activation at 12 months.”

The authors conclude, “The major limitation of this study is that it was not a randomized prospective study designed to directly compare the 2 modalities with a uniform protocol and consecutive enrollment. It is important to also note that interim clinical end points measured after only 12 months of immunotherapy likely do not provide a full assessment of the efficacy of either method. Further research is needed to determine the optimal length of treatment, dose, and ideal immunotherapy candidate for each modality.”

Skin and Blood Tests Sketchy for Diagnosing Venom Allergy
In an article in Annals of Allergy, Asthma, and Immunology author Daniel B.K. Golden says:
“A surprising proportion (up to 30% in several large studies) of people with a history of systemic reaction to a sting have negative venom skin test results. However, many of these individuals have positive serum IgE test results, leaving approximately 15% of history-positive patients with no detectable venom specific IgE. In sting challenge studies, only approximately 6% of such individuals have a systemic reaction to a challenge sting.4 There are many potential reasons for venom skin test results to be negative despite a convincing history. The test results can be negative in 20% to 50% of patients during the refractory period soon after a sting reaction but are positive 4 to 6 weeks after the sting. Another possible problem is the inherent variability of venom skin tests, which can reveal a 10-fold increase or decrease in the concentration for a positive result when performed weeks or months apart.5 The clinical implication is the potential to omit a venom in treatment when a subsequent test could have a positive result. The limited predictive value of the available diagnostic tests has spurred the development of new methods and materials for improved accuracy.

“Given the limited positive predictive value of venom tests, one must consider very carefully the potential consequences of a positive test result and the relative indication to perform the test. The relative risk of a severe reaction can be estimated from the history of previous reactions. Diagnostic tests are clearly indicated in those at high risk for reactions but should be avoided in low-risk individuals. It is a fallacy to think that performing the tests will help to make the clinical decision about starting VIT. In fact, the opposite can be true in that a positive test result in a low-risk individual will often create increased fear of reaction even though the history might indicate less than a 3% chance of needing epinephrine after a sting. The clinician should have a thorough discussion with the patient before the test is even performed about what the clinical recommendation will be and to discourage testing when the history indicates that VIT is not necessary.”

Management of Eosinophilic Esophagitis
The new issue of In Practice has extensive information about this troubling disease, including a specific description of the role that allergists should play in diagnosis and management. “The role of the allergist in the diagnosis and management of EoE includes (1) evaluating for and managing comorbid atopic disease(s) that may contribute to EoE (eg, aeroallergen-induced seasonal variation); (2) identifying allergic triggers and managing dietary avoidance; (3) determining whether a patient should be prescribed injectable epinephrine therapy, instructing a patient in its usage, and conducting office-based food challenges during the course of food reintroduction; (4) managing anti-inflammatory medications, including systemic or topical corticosteroids; and (5) educating the patient and/or family on the role and mechanisms of food triggers in EoE. Concerning dietary avoidance therapy, analysis of the data suggests that an elemental diet, SFED, or test-guided diet all can potentially result in symptomatic and histologic change, although these diets differ significantly in the number of potential foods eliminated and thus potential impact on QoL and nutrition.”

Immunotherapy Adherence Better if Started Before Economic Hard Times
“Studies [in Spain] on adherence to allergen immunotherapy (IT) show that patients and clinicians blame high cost, inconvenience, and lack of efficacy for nonadherence to treatment… [P]atients who initiated IT before the development of the current global economic crisis have better adherence compared with those treated during the recession period.” More

Current and Future Directions in Pediatric Allergic Rhinitis
Highlights of article in the current issue of In Practice is full of interesting information:
“AR is associated with significant morbidity and also affects patients’ quality of life (QoL), emotional well-being, productivity, and cognitive functioning. Many of these issues are related to poor sleep quality and sleep disturbances caused by AR. AR also places a large economic burden on the US health care system and includes both direct and indirect costs. Indeed, one recent estimate places the total annual costs of AR at approximately $11.2 billion, which is double the estimated cost in 2000….
“Recent studies have reported that the use of SIT (specific iimmunotherapy) in children with AR can decrease the risk of subsequent development of asthma. Novembre et al showed that children on SLIT to grass pollen were 3.8 times less likely to develop asthma after 3 years than the control subjects. Similarly, Niggemann et al showed that children treated for 3 years with subcutaneous immunotherapy (SCIT) to grass and/or birch pollen had significantly less asthma after 5 years (OR, 2.68; 95% CI, 1.3-5.7)….
“Diagnostic methods are of concern, with allergists predominantly conducting skin testing and general practitioners and pediatricians generally testing for allergen-specific IgE in the blood. The blood test was formerly called RAST, but over the past 20 years, many technological advances have made that original test obsolete. Newer, more advanced, accurate, and sensitive tests have replaced the RAST test. This includes the ImmunoCAP Specific IgE blood test, which provides a significant improvement over the original RAST test. It is the most sensitive testing method available today and is a highly accepted method used throughout the world, including the United States….
“Access to the care of allergists and the management of AR will undoubtedly be affected by the reform of the American health care system. The sources of payment, including government, employer, insurers, and individuals, will be instrumental in determining the direction of AR health care in the United States….
“Treatment of AR begins with environmental controls to reduce allergen exposure. Pharmacologic intervention is often required to control moderate-to-severe symptoms, and the mainstay of treatment consists of intranasal corticosteroids (INCSs), oral and intranasal antihistamines (AHs), oral and topical decongestants, and leukotriene receptor antagonists. Concerns over potential systemic side effects of INCSs in pediatric patients include growth effects and cortisol suppression. Specific immunotherapy (SIT) is an effective treatment for AR, but its use in pediatric patients is limited by inconvenience and safety concerns. The development of sublingual immunotherapy (SLIT) for the treatment of AR may offer a safer and more convenient route of treatment for pediatric patients and has the potential to offer disease-modifying and preventative activity if introduced at an early age.”
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New Insights into Atopic Dermatitis: Role of Skin Barrier and Immune Dysregulation
Donald YM Leung, MD, PhD Professor; Head, Division of Pediatric Allergy and Immunology; Department of Pediatrics at National Jewish Health Center in Denver has a thorough review article about atopic dermatitis (eczema) in Allerology International.
“Abstract: Atopic dermatitis (AD) is a chronic inflammatory skin disease that is often associated with the development of food allergy and asthma. New insights into AD reveals an important role for structural abnormalities in the epidermis resulting in a leaky epithelial barrier as well as chronic immune activation that contribute to the pathophysiology of this common skin disease. Patients with AD have a predisposition to colonization or infection by microbial organisms, most notablyStaphylococcus aureus and herpes simplex virus (HSV). Measures directed at healing and protecting the skin barrier and controlling the immune activation are needed for effective management of AD. Early intervention may improve outcomes for AD as well as reduce the systemic allergen sensitization that may lead to associated allergic diseases in other organs.”
Read the full article here.

Kids With Asthma Symptoms Bad Enough to Impair Sleep Suffer in School
Science Daily (May 21, 2013) “Compared with children with well-controlled asthma, those with poorly controlled asthma had lower quality school work and were more careless with their school work, according to teacher reports. Higher self-reported and objectively measured asthma symptom levels were associated with lower quality school work. Poorer sleep quality was also associated with careless school work. Increased sleep onset latency (the amount of time children take to fall asleep) was associated with more difficulty in remaining awake in class.

“‘Our findings demonstrate the detrimental effects that poorly controlled asthma may have on two crucial behaviors that can enhance overall health and development for elementary school children; sleep and school performance,’ said Dr. Koinis-Mitchell. ‘Urban and ethnic minority children are at an increased risk for high levels of asthma morbidity and frequent health care utilization due to asthma. Given the high level of asthma burden in these groups, and the effects that urban poverty can have on the home environments and the neighborhoods of urban families, it is important to identify modifiable targets for intervention.'”
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European Study Shows Immunotherapy Compliance Low in Third Year, Costing Patients Money and their Health
“Overall, only 18% of users reached the minimally required duration of treatment of 3 years (SCIT, 23%; SLIT, 7%). Median durations for SCIT and SLIT users were 1.7 and 0.6 years, respectively (P < .001). Other independent predictors of premature discontinuation were prescriber, with patients of general practitioners demonstrating longer persistence than those of allergologists and other medical specialists; single-allergen immunotherapy, lower socioeconomic status; and younger age. Of the persistent patients, 56% were never late in picking up their medication from the pharmacy. Direct medication costs per nonpersistent patient discontinuing in the third year of treatment were €3800, an amount that was largely misspent.”
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CDC Trends in Allergic Conditions Among Children: United States, 1997–2011
Key findings
Data from the National Health Interview Survey, 1997–2011
• The prevalence of food and skin allergies increased in children under age 18 years from 1997–2011.
• The prevalence of skin allergies decreased with age. In contrast, the prevalence of respiratory allergies increased with age.
• Hispanic children had a lower prevalence of food allergy, skin allergy, and respiratory allergy compared with children of other race or ethnicities. Non-Hispanic black children were more likely to have skin allergies and less likely to have respiratory allergies compared with non-Hispanic white children.
• Food and respiratory allergy prevalence increased with income level. Children with family income equal to or greater than 200% of the poverty level had the highest prevalence rates.
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Hygiene Hypothesis at Home–Parental Saliva on Pacifiers May Reduce Allergy Risk
A study published in Pediatrics indicates that parents who clean their children’s pacifiers by putting them in their own mouths may reduce their risk of allergies. “Exposure of the infant to parental saliva might accelerate development of a complex oral/pharyngeal microbiota that, similar to a complex gut microbiota, might beneficially affect tolerogenic handling of antigens by the oral/pharyngeal lymphoid tissues,” according to Bill Hesselmar, MD, PhD, of Queen Silvia Children’s Hospital in Gothenburg, Sweden, and colleagues. “Moreover, oral bacteria are swallowed and hence also affect the composition of the microbiota in the small intestine, which may in turn regulate tolerance development in the gut.” The study joins others in suggesting that changing an infant’s microbiota may influence the development of allergic disorders, according to Amal Assa’ad, MD, of Cincinnati Children’s Hospital Medical Center, and tells clinicians “that we have to let nature play out a little bit and not be too clean and not be forming artificial barriers in the connection between the mother and the infant and the parents and the infant.”
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Non-Respiratory Symptoms Visible in Kids in Days Before Loss of Asthma Control
A letter from several researchers to the new issue of In Practice asserts that non-respiratory symptoms such as “paleness, irritability, anxiety, tension, tiredness, and sleeping problems, among others, showed significant increases in likelihood within the 5 days before an episode” and were more common than upper respiratory symptoms such as mild cough and itchy throat.
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“Dustless” Chalk May Spell Bad News for Milk-Allergic Students A new study published in the Annals of Allergy, Asthma & Immunology says that so-called dustless chalk may contain casein, an allergenic milk protein. As reported in Science Daily, “‘Chalks that are labeled as being anti-dust or dustless still release small particles into the air,’ said Carlos H. Larramendi, MD, lead study author. ‘Our research has found when the particles are inhaled by children with milk allergy, coughing, wheezing and shortness of breath can occur. Inhalation can also cause nasal congestion, sneezing and a runny nose.'”

Children Born Outside the United States Have Lower Rates of Allergies Than Native Born However, the difference shrinks after a decade of residence, according to an article in JAMA Pediatrics.

Primrose Oil, Borage Oil—Alternative Eczema Treatments—Shown Ineffective
The New York Times Science section cites “a large new study suggests that people using evening primrose oil for eczema may want to save their money instead. In the study, a review of evidence published in The Cochrane Library, researchers looked at data from 27 studies involving either evening primrose oil and a similar supplement, borage oil, which is also rich in gamma linoleic acid. The studies, which included about 1,600 adults and children, compared the supplements to placebo. The researchers did not find that taking either supplement allayed eczema any more than taking dummy pills. But they did find a potential risk. Evening primrose oil can have anticoagulant effects that increase the risk of bleeding, something that is especially dangerous for people already taking blood-thinning drugs like warfarin.”
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Review Shows Sublingual Immunotherapy [SLIT] for Allergic Rhinitis and Conjunctivitis is Safe and Effective
Giovanni Passalacqua, Valentina Garelli, Francesca Sclifò, Giorgio Walter Canonica Immunotherapy. 2013;5(3):257-264
Abstract
Sublingual immunotherapy (SLIT) for allergic respiratory diseases was first described in 1986 and immediately appeared as a viable alternative to the traditional subcutaneous route. Since then, more than 60 randomized controlled trials have been published, almost all with very favorable results. The average improvement over placebo in symptom score and medication use was always greater than 20%. The results of the clinical trials were pooled in several meta-analyses, which consistently confirmed the efficacy of the treatment. SLIT is characterized by a satisfactory safety profile, its side effects being mainly limited to oral discomfort. Only six anaphylaxes and no fatalities have been so far reported. Due to the good risk:benefit ratio, SLIT is currently being investigated in diseases other than respiratory allergy, such as food allergy and atopic dermatitis.
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Eight Risk-Mitigating Behaviors for Airline Passengers with Food Allergies
A new article by Greenhawt, et all, in the Journal of Allergy and Clinical Immunology (JACI) lists 8 things that individuals might think about to protect passengers: “We highlight 8 the following potentially risk-mitigating behaviors: (1) making any request of the airline, (2) requesting a buffer zone, (3) requesting an announcement that passengers not eat peanut/tree nut–containing goods, (4) requesting a peanut/tree nut–free meal, (5) wiping their tray table, (6) bringing their own food from home, and (7) avoiding use of an airline-provided pillow, and (8) avoiding use of an airline-provided blanket. We also highlight international differences in the extent to which these behaviors are exhibited.”

“Allergen immunotherapy: Much more than a shot in the dark” An editorial in the Journal of Allergy & Clinical Immunology (JACI) says new research on allergy shots (Hankin et al. Allergen immunotherapy and health care cost benefits for children with allergic rhinitis: a large-scale, retrospective, matched cohort study. Ann Allergy Asthma Immunol.2010;104:79–85) ”shows that it is not only very effective but yields cost benefits very early in the course of treatment. The benefits for patients under 18 years of age are even great than for older patients. Using data from Florida Medicaid, “They found that AIT-treated subjects had significantly lower average total health care costs than matched controls, with cost reductions observed within 3 months of starting AIT. The cost reductions (30% in adults, 42% in children) remained significant when each group was analyzed separately…Total outpatient cost savings over 18 months from the initiation of AIT were nearly 3 times greater in AIT-treated children than in AIT-treated adults.”
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Road Traffic Pollution as Serious as Passive Smoke in the Development of Childhood Asthma Science Daily Mar. 21, 2013 — New research conducted in 10 European cities has estimated that 14% of chronic childhood asthma is due to exposure to traffic pollution near busy roads. The results are comparable to the burden associated with passive smoking: the World Health Organization estimates that between 4% and 18% of asthma cases in children are linked to passive smoking.

The findings, published online today (22 March 2013) ahead of print in theEuropean Respiratory Journal, come as the European Commission has declared 2013 the ‘Year of Air’, which highlights the importance of clean air for all and focuses on actions to improve air quality across the EU.

Until now, traffic pollution was assumed to only trigger asthma symptoms and burden estimations did not account for chronic asthma caused by the specific range of toxicants that are found near heavily used roads along which many Europeans live.
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Omalizumab (Xolair) Effective in Treating Stubborn Idiopathic Urticaria
Phase 2 trials (funded by Genetech and Novartis—makers of Xolair) shows that omalizumab, an IgE monoclonal antibody that targets IgE and affects mast-cell and basophil function, has shown efficacy for patients with chronic urticaria that doesn’t respond to antihistamine treatment. Xolair is currently used to treat severe asthma (at approximately $1000 per month).
More in the New England Journal of Medicine.

Asthmapolis Study Shows Effectiveness of App for Compliance
MADISON, Wis., March 5, 2013 /PRNewswire/ — Asthmapolis today announced an investigation featuring the system in the remote monitoring of inhaled bronchodilator use and weekly feedback about asthma management has been published in the latest issue of the scientific journal PLOS ONE. The study found improved asthma control and a decline in day-to-day asthma symptoms for participants receiving Asthmapolis’ weekly email reports and online charts summarizing inhaler use and location. The team monitored inhaler use for four months using the Asthmapolis system, and participants completed periodic surveys, including the Asthma Control Test™ (ACT) to assess changes in asthma control. After the first month, participants received weekly email reports for the remainder of the study period that summarized their inhaler use during the preceding week and provided self-management suggestions derived from National Asthma Education and Prevention Program guidelines.

No significant changes in asthma control appeared during the first month, however, after participants began receiving email reports and online information about their inhaler use, mean ACT scores increased 1.40 points for each subsequent month in the study. At the conclusion of the study period, 75% of participants had controlled asthma (by ACT score) compared with 38% at entry.

Lead author is David Van Sickle PhD who described the technology on this website two years ago. Read about it here.

Belief in God Makes Asthma Patients Less Likely to Take their Medicine
Medication adherence is a major contributor to disease outcomes across a spectrum of diseases, especially chronic conditions such as asthma. Barriers to adherence include patient factors such as low prioritization, physician factors such as the prescribing of complex medication regimens, and health care delivery or financing issues. Researchers in Michigan and Maryland hypothesized that belief in God was an underrated risk factor in not taking medication regularly.

They found, “patients who believe that God (or a higher power) determines their health are less likely to be adherent to their asthma controller medication. Belief in God does not equate to belief that God determines health. As such, this study found that patient’s who believe that God determines health outcomes were less adherent—not that those who believe in God were less adherent. It is also possible that individuals believe that multiple factors (eg, physicians or God/high power) coexist to determine health outcomes.”
More here.

Infant Gut Microbiota Influenced by Cesarean Section and Breastfeeding Practices; May Impact Long-Term Health
Feb. 11, 2013 — Science Daily reports that the method of birth (vaginal birth s. cesarean delivery) and feeding practices (breastfeeding v. formula-feeding) influence the development of gut bacteria in newborns and thus may affect lifelong health, according to a new study in CMAJ (Canadian Medical Association Journal).

“Our study addresses an important knowledge gap, since the infant gut microbiota has rarely been characterized with sequencing methods that provide sufficient coverage of the entire bacterial community,” writes Dr. Anita Kozyrskyj, University of Alberta, with coauthors. “Our findings are particularly timely given the recent affirmation of the gut microbiota as a “super organ” with diverse roles in health and disease, and the increasing concern over rising cesarean delivery and insufficient exclusive breastfeeding in Canada.”

For more on the role of gut bacteria and allergies, click here.

Adult Onset Asthma Linked to Jobs
The type of jobs people have may increase their risk for developing asthma as an adult, according to a new British study published online Jan. 21 in the journal Thorax. Researchers found one in six cases of the condition was linked to the workplace. Adult asthma was clearly associated with 18 different occupations, particularly cleaning jobs where people are exposed to chemicals. Other leading job categories were farming, hairdressing and printing (in which exposure to chemicals is also common—editor). The study involved 7,500 British adults born in 1958. Using the Asthma Specific Job Exposure Matrix, the researchers then calculated the participants’ exposure to compounds with a known link to asthma, including respiratory irritants and high-risk agents such as flour, enzymes, cleaning or disinfectant products, metal and metal fumes, and textile production. Of the study’s participants, 25 percent were smokers by the time they were 42. At this age, 9 percent of the adults had asthma and 87 percent had jobs. More than half, or 55 percent, of those who were employed had office jobs.

JACI Launches New Journal Called “In Practice” Think it’s time for practicing allergists to pay more attention to “best practices” in their work? So does the American Academy of Allergy, Asthma and Immunology. Their publication Journal of Allergy and Clinical Immunology (JACI) says in the inaugural editorial, “The emphasis of the journal will be on information that is practical for clinicians—material that can be used in everyday practice or will help in acquiring new knowledge or skills that can be directly applied to patients. Mechanistic or translational studies without immediate or near future clinical relevance will not be included.” The first issue is all about food allergies. For the table of contents click here.

Two Top Allergists Review the State of Food Allergy Knowledge and Treatment
Stacie M. Jones, MD and A. Wesley Burks, MD take a comprehensive look at diagnosis, treatment, the law, and advocacy. Among the highlights:
“Although the National Institute of Allergy and Infectious Disease guidelines are a huge leap forward, they also help to identify key knowledge gaps; there is still a lack of clear directives on day-to-day care of patients with food allergy. The guidelines emphasize consistent diagnostic criteria and firm evidence-based management strategies. They also highlight the fact that significant work is needed with regard to non–IgE-mediated disorders and eosinophilic gastrointestinal diseases.
“The current evidence base does not support broad clinical use of CRD (component-resolved diagnostics) testing for the diagnosis of food allergy, but CRD might prove to be very useful in the future.
to date, we do not yet have enough evidence to make firm recommendations about the timing of major food allergen introduction.
“The very modest reimbursement for OFC (oral food challenge) has been identified as a major barrier resulting in underuse of this very effective diagnostic tool.
“Food allergy advocates have also been encouraging legislation directed at restaurants and other eating establishments based on data reporting that 55% of peanut- or tree nut–reactive subjects did not notify the restaurant of their allergy, and 78% reported that someone in the restaurant knew that peanut or tree nut was an ingredient.
“The development of true immunologic and clinical tolerance remains controversial in food allergy therapeutics and will continue to be an area of active research. The concept of ‘sustained unresponsiveness’ has been introduced as a more relevant descriptive term of a subject who can consume ad libitum (at one’s pleasure) a previously known food allergen after completion of treatment. Current clinical trials primarily focus on IgE-mediated food allergy, and although they remain investigational, they hold tremendous promise for the future.”
The Journal of Allergy and Clinical Immunology
Volume 131, Issue 1 , Pages 3-11, January 2013

Early-life environmental determinants of allergic diseases and the wider pandemic of inflammatory noncommunicable diseases
(By Australian allergist and author, Dr. Susan Prescott
“Dramatic environmental and lifestyle changes of the modern age pose a significant threat to human health. An unparalleled increase in a diverse range of chronic noncommunicable diseases (NCDs) is one of the major global challenges of the 21st century. This growing burden of NCDs currently poses the greatest threat to health in both developed and developing regions and is a major barrier to human development. The dominant focus of the NCDs agenda is usually on “the big four”: cardiovascular disease, metabolic disease (obesity and type 2 diabetes), cancer, and chronic lung disease. Although both asthma and smoking-related diseases are considered in the context of chronic lung disease, allergic diseases per se are typically overlooked in this agenda, despite now being the most common and earliest-onset NCDs in most regions. Already, approximately 30% to 40% of the world’s population is affected by 1 or more allergic conditions, with vast personal, social, and economic costs….Unless we consider the wider social, cultural, and economic determinants of health in this context, we cannot hope to overcome the growing burden of allergy and other NCDs. For this reason, more than ever, it is important that we move toward more interdisciplinary collaboration and more multisectorial engagement to understand and address the complex determinants of health and disease in the modern world. Common strategies will be required to mitigate the growing burden of a broad range of modern diseases, and we need to urgently develop effective strategies to restore traditional dietary and lifestyle patterns, which clearly have many properties that protect not only against allergic disease but also against cardiovascular disease, obesity, diabetes, and many other NCDs.”
The Journal of Allergy and Clinical Immunology
Volume 131, Issue 1 , Pages 23-30, January 2013

Exercise-Induced Asthma Elevated in Asthma “Hot Spots” with Higher Black-Carbon Levels
Science Daily Dec. 17, 2012 — Asthmatic children in New York City neighborhoods with high rates of asthma make many more visits to the emergency room (ER) than those who live in other parts of the city. While socioeconomic factors such as lack of adequate preventive care are part of the equation (high-asthma neighborhoods tend to be lower income), new research points to a possible biological basis for the disparity. Asthmatic children living in asthma hotspots were twice as likely to experience a common symptom known as exercise-induced wheeze than were those in neighborhoods with lower asthma rates.

Results by researchers at Columbia University Medical Center and Dartmouth-Hitchcock Medical Center appear online in Pediatrics, the journal of the American Academy of Pediatrics. One of the researchers, Matthew Perzanowski, PhD at Columbia, was the subject of a post by Dr. Ehrlich here.

Peanut Protein Allergenicity May Be Reduced by Cooking Methods
Peanuts have attracted little attention in Korea because the prevalence of peanut allergy appears to be low. A study was conducted to determine what peanut allergens were involved in allergic reaction in Koreans and to investigate whether the cooking method used in Korea influences the reactivity of peanut protein to peanut specific IgE (sIgE). Increased allergenicity of Ara h 2 was induced by roasting, whereas other cooking methods produced no change or even reduced allergenicity of Ara h 2.
Annals of Allergy, Asthma & Immunology
Volume 110, Issue 1 , Pages 34-38, January 2013

Research Puts Annual US Food Allergy Costs to Families at $25 Billion
ANAHEIM, Calif. – Coverage of the ACAAI meeting in MedPage Today cites research showing food allergy costs for an average American child topping $4,000, with less than 20% of that attributable to direct medical expenses. Ruchi Gupta, MD, MPH, of Northwestern University in Chicago, led a survey of 1,643 parents with food-allergic children. More than half the cost comes from career sacrifices by parents including having to change or leave jobs, take part-time work, or otherwise give up income in order to care properly for a child. Extrapolated to the entire U.S. the total economic burden amounts to about $25 billion annually, broken down as follows:
• Direct medical costs: $724 per child, $4.3 billion nationally
• Out-of-pocket costs: $931 per child, $5.5 billion nationally
• Lost work productivity: $130 per child, $0.8 billion nationally
• Forgone work opportunities: $2,399 per child, $14.2 billion nationally
The per-child total summed to $4,184 (95% CI $3,475 to $4,960), Gupta said, with a national annual burden of $24.8 billion. The parental share, excluding the direct medical costs covered by third-party payers, was $3,457 annually. Previous research by Gupta and colleagues released last year, that found the U.S. prevalence of food allergy in children and teens had reached 8%, or 6 million.

Parent-Reported Child Food Allergies Often Unsubstantiated
THURSDAY, Sept. 20 (HealthDay News) — Nearly one-third of parent-reported food allergies are not formally diagnosed by a physician, according to a study published online Sept. 3 in the Journal of Allergy and Clinical Immunology. Ruchi S. Gupta, M.D., M.P.H., from the Northwestern University Feinberg School of Medicine in Chicago, and colleagues analyzed data from children with food allergy identified from a representative survey administered in U.S. households with children, from June 2009 to February 2010.
The researchers found that 2,355 children from the sample of 38,480 children had 3,218 allergies to nine common food allergens. A physician diagnosed 70.4 percent of reported food allergy. Among food allergies diagnosed by a physician, 32.6 percent were not assessed with diagnostic testing, while 47.3, 39.9, and 20.2 percent, respectively, were assessed with a skin prick test, a serum specific immunoglobulin E test, and an oral food challenge. For severe food allergy, the odds of physician diagnosis and testing were significantly higher than for mild/moderate food allergy. For severe food allergies, urticaria and angioedema were not reported as symptoms in 40.7 and 34.6 percent of cases, respectively.
“The majority of reported food allergy is diagnosed by a physician and is associated with some form of testing, However, 30 percent of parent-reported food allergy in this study was not diagnosed by a physician,” the authors write. “True food allergy that goes undiagnosed or diagnosed food allergy that is not appropriately substantiated places children at increased risk for poor outcomes.”

European Study Examines Bullying of School Children with Asthma
ScienceDaily (Sep. 2, 2012) 
Researchers from the Derbyshire Children’s Hospital, in the UK looked at the factors associated with an increased risk of bullying. Factors such as a reduced participation with sport and feelings of sadness were significantly associated with an increased risk of bullying. Additionally, factors that could be improved, such as poor asthma control, parental smoking and parents’ on-going worries about their child’s health, were also associated with bullying.

Dr Will Carroll, from the Derbyshire Children’s Hospital, said: “Our findings emphasise the need for doctors and nurses to speak to their patients about the effects their condition has on all aspects of their life. We know that bullying is associated with asthma and these findings can help us understand why this is case…As doctors, we must work with families to ensure these risk factors are removed and work with schools and teachers to ensure children with asthma are able to participate in sports at a level that is safe for them.”
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New CoFAR Study Shows Success for Oral Immunotherapy for Egg Allergy in Kids
A. Wesley Burks, M.D., Stacie M. Jones, M.D., Robert A. Wood, M.D., David M. Fleischer, M.D., Scott H. Sicherer, M.D., Hugh A. Sampson, M.D. et al for the Consortium of Food Allergy Research (CoFAR) N Engl J Med 2012; 367:233-243July 19, 2012

RESULTS
After 10 months of therapy, none of the children who received placebo and 55% of those who received oral immunotherapy passed the oral food challenge and were considered to be desensitized; after 22 months, 75% of children in the oral-immunotherapy group were desensitized. In the oral-immunotherapy group, 28% (11 of 40 children) passed the oral food challenge at 24 months and were considered to have sustained unresponsiveness. At 30 months and 36 months, all children who had passed the oral food challenge at 24 months were consuming egg. Of the immune markers measured, small wheal diameters on skin-prick testing and increases in egg-specific IgG4 antibody levels were associated with passing the oral food challenge at 24 months.

Component Testing for Peanut Allergy Much More Accurate than Whole Peanut
Australian researchers have found:
“By using the previously published 95% positive predictive value of 15 kU(A)/L for whole peanut sIgE, a corresponding specificity of 98% (95% CI, 93% to 100%) was found in this study cohort. At the equivalent specificity of 98%, the sensitivity of Ara h 2 sIgE is 60% (95% CI, 50% to 70%), correctly identifying 60% of subjects with true peanut allergy compared with only 26% correctly identified by using whole peanut sIgE. We report that when using a combined approach of plasma sIgE testing for whole peanut followed by Ara h 2 for the diagnosis of peanut allergy, the number of OFCs required is reduced by almost two thirds.

“CONCLUSION:
Ara h 2 plasma sIgE test levels provide higher diagnostic accuracy than whole peanut plasma sIgE levels and could be considered a new diagnostic tool to distinguish peanut allergy from peanut tolerance, which might reduce the need for an OFC.”

Infants Exposed to Specific Molds Have Higher Asthma Risk
ScienceDaily (Aug. 2, 2012) —Cincinnati-based researchers report new evidence that exposure to three types of mold during infancy may have a direct link to asthma development during childhood. These forms of mold — Aspergillus ochraceus, Aspergillus unguis andPenicillium variabile — are typically found growing in water-damaged homes.

Lead author Tiina Reponen, PhD, and colleagues report these findings in the August 2012 issue of the Journal of Allergy and Clinical Immunology. They found that 25 percent of children whose parents had allergies were asthmatic by age 7. Among the multiple indoor contaminants assessed, only mold exposure during infancy emerged as a risk factor for asthma at age 7. “Previous scientific studies have linked mold to worsening asthma symptoms, but the relevant mold species and their concentrations were unknown, making it difficult for public health officials to develop tools to effectively address the underlying source of the problem,” explains Reponen, who is a professor in the UC College of Medicine’s environmental health department. The UC-based team used the environmental relative moldiness index (ERMI), a DNA-based mold level analysis tool, to determine that exposure to Aspergillus ochraceus, Aspergillus unguis and Penicillium variabile was linked to asthma development in the high-risk study population.
For more on mold, click here.

Oral Immunotherapy for Egg Allergy Gets Boost from New Study
ScienceDaily (July 18, 2012) — Doctors currently have only one recommendation for people allergic to eggs: avoid eggs completely. But researchers at the University of North Carolina School of Medicine recently found promise in doing just the opposite. Eating small amounts of egg every day for many months lowered the threshold for allergic reactions in 75 percent of egg-allergic children; 28 percent were able to incorporate egg into their regular diets after two years on the treatment.

“It’s just what we had hoped for,” said Wesley Burks, MD, Curnen Distinguished Professor and Chair of the UNC Department of Pediatrics and the study’s lead author. “It’s what we anticipated based on earlier studies, but we weren’t sure it would happen. Almost a third of the children had a permanent change and were no longer egg-allergic.” The study appears online July 19, 2012, in the New England Journal of Medicine. Burks cautioned that the treatment is not yet ready for widespread adoption, however. “There are too many side effects that we don’t really understand, and it could be dangerous if it was done by a family in a home,” said Burks. “More studies are needed to understand the safety aspects better.”

The study was organized by the Consortium of Food Allergy Research (CoFAR). Co-authors include Brian P. Vickery of UNC; Stacie M. Jones and Amy M. Scurlock of the University of Arkansas for Medical Sciences and Arkansas Children’s Hospital; Robert A. Wood of the Johns Hopkins University Medical Center; David M. Fleischer and Andrew H. Liu of National Jewish Health; Hugh A. Sampson and Scott H. Sicherer of the Mount Sinai School of Medicine; Robert W. Lindblad, Donald Stablein and Alice K. Henning of The EMMES Corporation; Wayne G. Shreffler of Massachusetts General Hospital, Harvard Medical School; and Marshall Plaut of the National Institutes of Health.
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Asthma Linked to Congested Highways: Brooklyn, NY Study Finds Clusters Near Famous Gowanus Expressway
ScienceDaily (June 26, 2012) — Researchers at SUNY Downstate Medical Center and Lutheran Medical Center in Brooklyn, New York, found that living near a heavily congested highway correlates with a higher presence of asthma. In a study published in the Journal of Allergy and Clinical Immunology, the researchers found higher rates of asthma among those living closer to Interstate 278, near a portion known locally as the Gowanus Expressway, and lower rates of disease in those living in the same community but farther from the Interstate.

SUNY Downstate’s Maria-Anna Vastardi, MD, said, “Our participants were randomly recruited and we observed that the patients who reported asthma live significantly closer to the Gowanus Expressway, compared to the healthy controls who live in the same area, but at a longer distance from the Gowanus.” The findings indicate that proximity to a heavily trafficked highway correlates with the presence of asthma in adults, but not with seasonal allergy, according to Dr. Vastardi. The results suggest that vehicle emissions may increase the risk for developing inflammatory lung disease in adults.
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{Note: For more on the connection between neighborhood air and asthma, click here.}

Anaphylaxis Knowledge among Paramedics: Results of a National Survey
JJacobsen RC, et al
Prehosp Emerg Care. 2012 Jun 19. [Epub ahead of print]
“Conclusions. Whereas a large percentage of the paramedics recognized classic anaphylaxis, a very small percentage recognized atypical anaphylaxis. Less than half chose epinephrine as the initial drug of choice, and most respondents were unable to identify the correct route/location of administration.”
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Omalizumab (Xolair) Linked to Fewer Emergencies, Lower-Doses of Asthma-Control Meds for Uncontrolled Asthma Patients
Annals of Allergy, Asthma & Immunology; Volume 109, Issue 1 , Pages 59-64, July 2012
Marie-Hélène Lafeuille, MA, Jason Dean, PhD, Jie Zhang, PhD, Mei Sheng Duh, MPH, ScD, Boris Gorsh, PharmD, Patrick Lefebvre, MA

“Results In total, 644 patients (mean age, 49.9; female, 59.2%) formed the study population. Omalizumab was associated with a 48.6% reduction in the proportion of patients with 1 or more asthma-related ED visits (pre vs post-omalizumab period: 21.4% vs 11.0%; P < .001) and a 40.8% reduction in asthma-related hospitalizations (25.0% vs 14.8%, respectively, P < .001). Compared with the pre-omalizumab period, the use of ICS decreased significantly after omalizumab initiation (7.8 vs 6.5 dispensings, P < .001; 41.9% of patients had a reduction in ICS use). A similar reduction in oral corticosteroid use was observed (5.0 vs 3.6 dispensings, P < .001; 53.3% of patients had a reduction in oral corticosteroid use).

“Conclusion The current analysis showed that omalizumab treatment initiation was associated with significant reductions in ED visits, hospitalizations, and corticosteroid use.”
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Antibacterials in Personal-Care Products Linked to Allergy Risk in Children
ScienceDaily (June 19, 2012) — Exposure to common antibacterial chemicals and preservatives found in soap, toothpaste, mouthwash and other personal-care products may make children more prone to a wide range of food and environmental allergies, according to new research from Johns Hopkins Children’s Center. Results of the NIH-funded study are published online ahead of print June 18 in the Journal of Allergy and Clinical Immunology.

Using existing data from a national health survey of 860 children ages 6 to 18, Johns Hopkins researchers examined the relationship between a child’s urinary levels of antibacterials and preservatives found in many personal-hygiene products and the presence of IgE antibodies in the child’s blood. IgE antibodies are immune chemicals that rise in response to an allergen and are markedly elevated in people with allergies.

“We saw a link between level of exposure, measured by the amount of antimicrobial agents in the urine, and allergy risk, indicated by circulating antibodies to specific allergens,” said lead investigator Jessica Savage, M.D., M.H.S., an allergy and immunology fellow at Hopkins. The researchers caution that the findings do not demonstrate that antibacterials and preservatives themselves cause the allergies, but instead suggest that these agents play a role in immune system development.
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Egg Oral Immunotherapy
Brian P. Vickery, MD
Posted: 06/19/2012; Curr Opin Allergy Clin Immunol. 2012;12(3):278-282.
“Summary Egg OIT is a promising modality for providing temporary protection from reactions caused by accidental egg exposure. However, the overall strength of the evidence in favor of egg OIT is limited by small sample sizes and the lack of controls, both of which are important considerations given the spontaneous resolution expected in egg allergy. More high-quality studies are necessary before egg OIT can be recommended as a viable treatment option.”
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{Note: this article concurs with Dr. Hugh Sampson’s recent piece that food allergy OIT is promising but needs more study.}

Omalizumab (Xolair) Cuts Dependence on Oral Steroids in Children with Severe Asthma
Malcolm Brodlie, Michael C McKean, Samantha Moss, David A Spencer
Arch Dis Child archdischild-2011-301570Published Online First: 9 June 2012doi:10.1136/archdischild-2011-301570

“Conclusions A 16-week therapeutic trial of omalizumab allowed a significant reduction in daily prednisolone dose and was associated with improvements in asthma control and quality of life in 34 children with severe asthma. Similar benefits were seen in children both above and below 12 years of age. These uncontrolled data are very encouraging. There is an urgent requirement for a multicentre randomised placebo-controlled trial of omalizumab in children with severe asthma, with reduction in oral corticosteroid dose as the primary outcome measure.”
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{Note: a couple of years ago, the British National Health Service restricted use of Omalizumab for children, saying it offered little advantage over existing drugs. Our two resident doctors, Larry Chiaramonte, Paul Ehrlich, and a guest, Dr. Janet Sullivan, medical director for Hudson Health Plan in New York State found grounds for argument in a special Roundtable.}

City Kids More Likely to Have Food Allergies Than Rural Ones: Population Density Is Key Factor, Study Finds
ScienceDaily (June 7, 2012) — Children living in urban centers have a much higher prevalence of food allergies than those living in rural areas, according to a new study, which is the first to map children’s food allergies by geographical location in the United States. In particular, kids in big cities are more than twice as likely to have peanut and shellfish allergies compared to rural communities. The study will be published in the July issue of Clinical Pediatrics.

“We have found for the first time that higher population density corresponds with a greater likelihood of food allergies in children,” said lead author Ruchi Gupta, M.D., an assistant professor of pediatrics at Northwestern University Feinberg School of Medicine and a physician at the Ann & Robert H. Lurie Children’s Hospital of Chicago (formerly Children’s Memorial). “This shows that environment has an impact on developing food allergies. Similar trends have been seen for related conditions like asthma. The big question is — what in the environment is triggering them? A better understanding of environmental factors will help us with prevention efforts.”
Key findings:
• In urban centers, 9.8 percent of children have food allergies, compared to 6.2 percent in rural communities.
• Peanut allergies are twice as prevalent in urban centers as in rural communities, with 2.8 percent of children having the allergy in urban centers compared to 1.3 percent in rural communities. Shellfish allergies are more than double the prevalence in urban versus rural areas; 2.4 percent of children have shellfish allergies in urban centers compared to 0.8 percent in rural communities.
• Food allergies are equally severe regardless of where a child lives, the study found. Nearly 40 percent of food-allergic children in the study had already experienced a severe, life-threatening reaction to food.
• The states with the highest overall prevalence of food allergies are Nevada, Florida, Georgia, Alaska, New Jersey, Delaware, Maryland and the District of Columbia.
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Why Hot, Humid Air Triggers Symptoms in Patients With Mild Asthma
ScienceDaily (June 6, 2012) — A study appearing in the June print issue of the American Journal of Respiratory and Critical Care Medicine, found that patients who inhaled an asthma drug before breathing in hot, humid air were able to prevent airway constriction that volunteers without asthma did not experience in the same environment.

“We know that breathing cold, dry air induces airway constriction in asthmatics,” said Don Hayes, MD, medical director of the Lung and Heart-Lung Transplant Program at Nationwide Children’s Hospital. “But the effects that temperature increases have on airway function in these patients are generally overlooked. We know very little about the mechanisms that cause symptoms when asthmatic patients are exposed to hot, humid air.”
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Component Testing Improves Prediction of Peanut Allergy; Could Reduce Reliance on Oral Food Challenge
J ALLERGY CLIN IMMUNOL VOLUME 129, NUMBER 4
A study published in the Journal of Allergy and Clinical Immunology (JACI) states:

“Measurement of whole peanut-specific IgE (sIgE) is often used to confirm sensitization but does not reliably predict allergy. Ara h 2 is the dominant peanut allergen detected in 90% to 100% of patients with peanut allergy and could help improve diagnosis.”

Component tests that show reactivity with Ara h 2 are now shown to be 95% predictive of true peanut allergy in one-year olds. Better diagnosis should help make it easier to manage family diets.

“In conclusion, Ara h 2 sIgE testing should be considered the preferred diagnostic tool for determining peanut allergy because we have shown greater diagnostic accuracy than that of whole peanut sIgE and SPT. This will reduce the need for an OFC and ultimately might reduce the strain and demand on clinical allergy services.”

Thanh D. Dang, BBiomedSc (Hons), Mimi Tang, MBBS, PhD, FRACP, FRCPA, FAAAAI, Sharon Choo, MBBS, FRACP, FRCPA, Paul V. Licciardi, PhD, Jennifer J. Koplin, PhD, Pamela E. Martin, BBiomedSc (Hons), Tina Tan, BSc, Lyle C. Gurrin, PhD, Anne-Louise Ponsonby, BMedSc, MBBS, PhD, FAFPHM, FRACP, Dean Tey, MBBS, FRACP, Marnie Robinson, MBBS, FRACP, Shyamali C. Dharmage, MBBS, MD, PhD, and Katrina J. Allen, BMedSc, MBBS, FRACP, PhD, for the HealthNuts study Parkville, Australia

A fresh perspective on asthma
Nature Medicine 18, 631 (2012) doi:10.1038/nm.2777
Published online 04 May 2012
“Recent advances in asthma research have altered views of how the disease is triggered and sustained. What remains to be seen is whether this knowledge can be integrated into the clinic to alter the natural course of disease.

“The global prevalence of asthma has markedly increased over the past 50 years, with an estimated 300 million people affected worldwide. Following the description of IgE and the T helper type 1 (TH1)/TH2 hypothesis, scientists made considerable headway identifying pathways necessary to initiate and sustain allergic responses. However, clinical trials targeting these pathways met with mixed results, and, despite symptomatic control of the disease, individuals still develop chronic disease and remain refractory to therapies.

“[The editors of] Nature Medicine reached out to 50 basic and clinical researchers in asthma and asked them to highlight key advances and obstacles in the field. These recent developments are discussed in depth in seven reviews in this issue of Nature Medicine. We are indebted to the authors of these reviews and to the investigators surveyed for their insight into the field. What emerges is a picture of a highly heterogeneous disease, influenced by complex genetic and environmental effects, and an evolving understanding of the key cell types and soluble mediators that orchestrate the immune response.”
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Is it an Attack or an Exacerbation?
“Long-term achievement of asthma control is dependent in part on the use of mutually understandable asthma terminology in all verbal and written patient-physician communications…Nearly all patients had heard the term ‘asthma attack’ (97%), but relatively few had heard the term ‘asthma exacerbation’ (24%); 71% had heard ‘asthma flare-up.’ In contrast, physicians reported using the term “asthma attack” least (65%) and the term ‘asthma exacerbation’ most (77%) when discussing asthma with their patients; 70% reported using ‘asthma flare-up.’ Among patients familiar with ‘asthma flare-up’ and ‘asthma exacerbation’ (n = 502), only 38% said that the terms mean the same thing; nearly all physicians (94%) said that the terms mean the same thing.”

Patient and physician asthma deterioration terminology: results from the 2009 Asthma Insight and Management survey.
Blaiss MS, Nathan RA, Stoloff SW, Meltzer EO, Murphy KR, Doherty DE.
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{Note: We are very aware that discrepancies in vocabulary can make a big difference in treatment. See Dr. Ehrlich’s piece on differences between allergists and emergency department doctors in their definition of anaphylaxis.}

Medical Costs for Patients with Asthma Exacerbations Twice Those Whose Asthma is Controlled Patients with exacerbations had significantly higher total health care costs ($9223 vs $5011, P < .0001) and asthma-related costs ($1740 vs $847, P < .0001). The cost differences remained significant after controlling for patient differences by using multivariate models. Patients with exacerbations (n = 3830) had higher rates of sinusitis, allergy-related diagnoses or medications, pneumonia, and mental disorders and higher average Charlson Comorbidity Index scores at baseline. Patients with exacerbations filled their prescriptions for controllers more often and had higher asthma-related drug costs.
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Boston Home Visit Program Shows Dramatic Improvement in Asthma Control
The Community Asthma Initiative run by Boston Children’s Hospital, which Dr. Chiaramonte wrote about here last year, continues to show excellent results. According to an article in Pediatrics:

“Twelve-month data show a significant decrease in any (?1) asthma ED visits (68.0%) and hospitalizations (84.8%), and any days of limitation of physical activity (42.6%), patient missed school (41.0%), and parent missed work (49.7%) (all P < .0001). Patients with greatest functional impairment from ED visits, limitation of activity, and missed school were more likely to have any nurse home visit and greater number of home visits. There was a significant reduction in hospital costs compared with the comparison community (P < .0001), and a return on investment of 1.46.”

The Atlantic reports on the program here. We wrote about this program in our book because of an article in the New Yorker by Dr. Atul Gawande which said, among other things, that the program represented a threat to the solvency of Boston Children’s because asthma exacerbations were a staple source of business.

Uncontrolled asthma and factors related to morbidity in an impoverished, rural environment
Tamara T. Perry, MD Mallikarjuna Rettiganti, PhD Rita H. Brown, BS Todd G. Nick, PhD Stacie M. Jones, MD
Published in the Annals of Allergy, Asthma, and Immunology
Asthma among the urban poor has been well studied but not the rural poor. This team “performed a cross-sectional investigation of 109 rural children with asthma enrolled in public schools in the Arkansas Delta region. A questionnaire format and home inspection were used to examine participant, caregiver, and home characteristics…

“The median age of the study participants was 9 years, 83% were African American, and 71% had an annual household income of $20,000 or less. Ninety-eight percent of participants were insured, and most fit the criteria for uncontrolled asthma, yet only 23% reported taking inhaled corticosteroids. Transportation problems were cited by 20%. In the past 4 weeks, more than 50% reported rescue medication use or exercise limitations of 2 or more days per week or nocturnal symptoms of more than 2 nights per month. Emergency department visits in the past 6 months were reported by 28%, and 43% reported an unscheduled physician’s visits for asthma in the past 3 months. Sixty-four percent had 1 or more positive allergen skin test results, and allergic sensitization was associated with exposure to dust mite, dog, mouse, and cockroach allergens in the home.
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Air Pollution from Trucks and Low-Quality Heating Oil May Explain Childhood Asthma Hot Spots

From Science Daily (Mar. 27, 2012) —According to a new study by scientists at Columbia University, neighborhood differences in rates of childhood asthma may be explained by varying levels of air pollution from trucks and residential heating oil.

Results appear online in the Journal of Exposure Science and Environmental Epidemiology.
In New York City, asthma among school-age children ranges from a low of 3% to a high of 19% depending on the neighborhood, and even children growing up within walking distance of each other can have 2- to 3-fold differences in risk for asthma. Helping explain these disparities, the researchers found that levels of airborne black carbon, which mostly comes from incomplete combustion sources like diesel trucks and oil furnaces, were high in homes of children with asthma. They also reported elevated levels of black carbon within homes in neighborhoods with high asthma prevalence and high densities of truck routes and homes burning low-grade or “dirty” heating oil.

The study’s senior author, Matthew Perzanowski, PhD, associate professor of Environmental Health Sciences at Columbia University says, “This study adds to the evidence that further public health interventions on oil and truck emissions standards and the use of dirty oil may be warranted. This is especially timely as New York City considers regulations to further reduce the burning of low-grade oil for domestic heating”

Dr. Ehrlich wrote about Perzanowski’s work here.

Study Supports the Hygiene Hypothesis
From Science Daily
Researchers at Brigham and Women’s Hospital (BWH) have conducted a study (published online in the journal Science on the Science Express Web site) that supports the hygiene hypothesis, and a potential mechanism by which it might occur.
“The researchers studied the immune system of mice lacking bacteria or any other microbes (“germ-free mice”) and compared them to mice living in a normal environment with microbes. They found that germ-free mice had exaggerated inflammation of the lungs and colon resembling asthma and colitis, respectively. This was caused by the hyperactivity of a unique class of T cells (immune cells) that had been previously linked to these disorders in both mice and humans. Most importantly, the researchers discovered that exposing the germ-free mice to microbes during their first weeks of life, but not when exposed later in adult life, led to a normalized immune system and prevention of diseases.”

Food Allergic Infants More Likely to Have Vitamin D Insufficiency
MITCHEL L. ZOLER, Skin & Allergy News Digital Network
ORLANDO – Vitamin D insufficiency at age 1 year was associated with a nearly fourfold increased prevalence of a food allergy in a case-control study of 269 children. The finding appears consistent with prior reports that linked the prevalence of food allergies to the latitude gradients for where people lived, Dr. Katrina J. Allen and her associates reported in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. Those reports had suggested that the further people lived from the equator, the higher their rate of hospitalizations for food-allergy related events, said Dr. Allen, a pediatric allergist and gastroenterologist at Royal Children’s Hospital Melbourne, and her associates.

The study involved 5,276 12-month old infants from the Melbourne area enrolled in the Health Nuts population-based study. All infants had skin prick tests to egg white, peanut, and sesame; 1,005 developed at least a 1 mm wheal to at least one of these foods. Of the 834 food-sensitized infants who returned to the clinic for an oral food challenge with egg, peanut, and sesame, 351 were identified as food allergic with at least three non-contact hives or areas of urticaria that persisted for at least 5 minutes; perioral or periorbital angioedema; or severe and persistent vomiting or anaphylaxis (J. Allergy Clin. Immunol. 2012;129[suppl.]:AB141).
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Economic Burden for Asthma in Thailand Average total per person annual cost in adults was 16,287.27 Baht (approximately USD 525.4). In 2008, there were 13.7 million children in Thailand; 10% suffered from asthma, so the economic burden of asthma in children for Thailand in the year 2008 was 10,972.36 million Baht (about USD 353.9 million).
* Per capita income (2010 prelim.): $4,716.
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Ten Principles for Cleaner Air in Europe
For the European “Year of the Air” in 2013, the European Respiratory Society Environment and Health Committee (www.ersnet.org) has developed 10 concise principles for clean air. For further information, read the editorial written to explain these 10 principles here.

1–Citizens are entitled to clean air, just like clean water and safe food.
2–Outdoor air pollution is one of the biggest environmental health threats in Europe today, leading to significant reductions of life expectancy and productivity.
3–Fine particles and ozone are the most serious pollutants. There is an urgent need to reduce their concentrations significantly.
4–Roadside pollution poses serious health threats that cannot be adequately addressed by regulating fine particle mass or ozone. Other metrics such as ultrafine particles and black carbon need to be considered in future research and so inform further regulation.
5–Non-tailpipe emissions (from brakes, tyres and road surfaces, etc.) pose a health threat for road users and subjects living close to busy roads.
6–Real-world emissions of nitrogen dioxide from modern diesel engines are much higher than anticipated. This may expose many road users, and subjects living on busy roads, to short-term peak concentrations during rush hours and periods of stagnating weather that may impact on health, although to what extent requires further research.
7–Global warming will lead to more heatwaves, during which air pollution concentrations are also elevated and during which hot temperatures and air pollutants act in synergy to produce more serious health effects than expected from heat or pollution alone.
8–Combustion of biomass fuel produces toxic pollutants. This is true for controlled fires, such as in fireplaces, woodstoves and agricultural burning, as well as for uncontrolled wildfires. There is a need to assess the real health impacts of air pollution from these sources in many areas in Europe to inform on the need for better control.
9–Compliance with current limit values for major air pollutants in Europe confers no protection for public health. In fact, very serious health effects occur at concentrations well below current limit values, especially those for fine particles.
10–EU policies to reduce air pollution are needed that ultimately lead to air that is clean and no longer associated with significant adverse effects on the health of European citizens. The benefits of such policies outweigh the costs by a large amount.

One-Third of Food Allergic Kids Bullied at School, Studies Show

According to research conducted in Jackson, Mississippi and New York City presented at the American Academy of Allergy, Asthma and Immunology in Florida this past weekend, one-third of food allergic children experience bullying at school. The New York survey—the second one done by a team based at Mt. Sinai led by Scott Sicherer, MD—“asked children eight to 17 years old and, separately, their parents about bullying the children had experienced.
“The overall prevalence of allergy-related bullying was 28.8% among the 111 families included in the study. A slightly higher proportion (32.6%) of those in sixth through 10th grade reported having been bullied for their allergies.
“Notably, Sicherer and colleagues found that, in 32% of allergy-related bullying cases reported by the children, their parents were unaware of it. And for 11 children who had reported being bullied more than once a month, 64% of parents did not know it.”
More here

Asthma Continues to Be Major Health Burden, according to Asthma Insight and Management (AIM) survey

“Asthma prevalence in the United States was estimated at 8%. Twice as many adult asthma patients rated their health as ‘only fair,’ ‘poor,’ or ‘very poor,’ or experienced limitations in activity because of health problems, compared with the general population. Asthma also frequently caused negative emotional symptoms in patients. Most patients experienced asthma throughout the year (63%) and symptoms within the 4 weeks before the summer survey (68%). Overall, 41% of patients responded that asthma interfered with their/their child’s life ‘some’ or ‘a lot.'”
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How Vitamin D Inhibits Inflammation
ScienceDaily (Feb. 23, 2012) — Researchers at National Jewish Health have discovered specific molecular and signaling events by which vitamin D inhibits inflammation. In their experiments, they showed that low levels of Vitamin D, comparable to levels found in millions of people, failed to inhibit the inflammatory cascade, while levels considered adequate did inhibit inflammatory signaling. They reported their results in the March 1, 2012, issue of The Journal of Immunology.

“This study goes beyond previous associations of vitamin D with various health outcomes. It outlines a clear chain of cellular events, from the binding of DNA, through a specific signaling pathway, to the reduction of proteins known to trigger inflammation,” said lead author Elena Goleva, assistant professor of pediatrics at National Jewish Health. “Patients with chronic inflammatory diseases, such as asthma, arthritis and prostate cancer, who are vitamin D deficient, may benefit from vitamin D supplementation to get their serum vitamin D levels above 30 nanograms/milliliter.”

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Boston Home Care Asthma Program Shows Big Savings

ScienceDaily (Feb. 20, 2012) reports that the Community Asthma Initiative (CAI), developed and implemented in 2005 by Children’s Hospital Boston, dramatically reduced hospitalization and emergency department visits for asthma — improving patient outcomes and saving $1.46 per dollar spent through reduced hospital utilization. (Note: Dr. Chiaramonte wrote about this program a year ago here.)

A study reporting these outcomes and cost savings appears in the March 2012 issue of Pediatrics (published online February 20). The CAI provides low-income families with nurse case management and care coordination, home visits by a bilingual nurse or Community Health Worker to educate families, assess the home for asthma triggers, and provide materials and services to improve the home environment, such as bedding, HEPA vacuums and pest control.

The CAI team, led by Elizabeth Woods, MD, MPH, of the Division of Adolescent/Young Adult Medicine, and Shari Nethersole, MD, of the Office of Child Advocacy at Children’s Hospital Boston, selected children from four low-income zip codes because they had been hospitalized or had made emergency department (ED) visits for asthma. Forty-three percent had asthma scored as moderate or severe. Families received an average of 1.2 home visits during the year-long program. “The environmental issues have been much greater than expected, with high rates of pest infestation and dust and mold problems,” Woods notes.

After 12 months the children had a 68 percent decrease from baseline in asthma-related ED visits and an 85 percent drop in hospitalizations. There was a 43 percent reduction in the percentage of children who had to limit physical activity on any day, a 41 percent reduction in reports of missed school days and a 50 percent reduction in parents having to miss work to care for their child. The percentage of children with an up-to-date asthma care plan rose from 53 percent at baseline to 82 percent at 12 months.

Improvements were evident within 6 months, and, among children who had follow-up, persisted for as long as two years. The program cost $2,529 per child, but yielded a savings of $3,827 per child because of reduced ED visits and hospitalizations.

Health Costs for Asthmatics with Exacerbations Much Higher Than Those Without

According to a study in the Journal of Allergy and Clinical Immunology, patients with moderate/severe persistent asthma who had exacerbations had significantly higher total health care costs than those without–$9223 vs $5011, with asthma-related costs $1740 vs $847. Patients with exacerbations had higher rates of sinusitis, allergy-related diagnoses or medications, pneumonia, and mental disorders and higher average Charlson Comorbidity Index scores at baseline. Patients with exacerbations filled their prescriptions for controllers more often and had higher asthma-related drug costs.

Burp! Soft Drinks Associated With Asthma and COPD

A new study published in Respirology shows a correlation between drinking lots of soft drinks—fizzy and not–associated with asthma and/or chronic obstructive pulmonary disease (COPD). Australian researchers conducted computer assisted telephone interviews with nearly 17 thousand participants aged 16 years and older inquiring about consumption of soft drinks including Coke, lemonade, flavored mineral water, Powerade, and Gatorade.

Results showed that one in ten adults drink more than half a liter of soft drink daily. There seems to be a dose-response relationship. Overall, 13.3% of participants with asthma and 15.6% of those with COPD reported consuming more than half a liter of soft drink per day.
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Does More Sunlight Mean Less Allergy and Eczema for Kids?

European and Australian researchers say that increased exposure to sunlight may reduce the risk of both food allergies and eczema in children. They found that Australian children living in areas with lower levels of sunlight are at greater risk of developing these conditions compared to those in areas with higher levels of ultra-violet rays from the sun. As reported in Science Daily, the data showed that on average children in the south of the country are twice as likely to develop eczema as those in the north.

Sunlight is important because it provides our body with the fuel to create vitamin D in the skin, and locations closer to the equator typically receive higher levels of sunshine. Australia is a good venue for this type of study as it spans nearly 3000 miles from north to south, with a large variation in climate, day length and sun strength. Lead researcher Dr. Nick Osborne, “This investigation has further underlined the association between food allergies, eczema and where you live. We’re now hoping to study these effects at a much finer scale and examine which factors such as temperature, infectious disease or vitamin D are the main drivers of this relationship. As always, care has to be taken we are not exposed to too much sunlight, increasing the risk of skin cancer.”

Dr. Osborne will be presenting the findings of the study at the American Academy of Allergy, Asthma & Immunology in Orlando on March 6th 2012. The study is published in the Journal of Allergy and Clinical Immunology this week.

Promising Results for Combo of Xolair Pre-Treatment and Rapid Milk Immunotherapy Nine severely dairy-allergic children out of nine who completed a 16-20 week course of omalizumab (Xolair) followed by increasing amounts of milk passed double-blind placebo-controlled food challenges (DBPCFC) 24 weeks after treatment. More here.

Social burden and economic impact of asthma
The social and economic burden of asthma exacerbations relates to the direct costs of health care use and the indirect costs associated with lost productivity. In the United States in 2007, there were 1.75 million (1.11 million for adults and 0.64 million for children) asthma-related emergency department visits and 456,000 (299,000 for adults and 157,000 for children) asthma-related hospitalizations. Hospitalization constitutes about one third of the total $14.7 billion in US annual asthma-related health care expenditures. The European Lung Foundation has estimated that the cost of asthma in the European Union is €17.7 billion, of which €9.8 billion is related to lost productivity. In the Real-world Evaluation of Asthma Control and Treatment survey 24% of adults and 53% of children had missed at least 1 day of work or school, respectively. Therefore the social and economic burden of asthma exacerbations remains considerable.

From the Journal of Allergy and Clinical Immunology

Top Allergists Tell Pediatricians About Limitations of Allergy Tests

ScienceDaily (Dec. 26, 2011) — An advisory from two leading allergists, Robert Wood of the Johns Hopkins Children’s Center and Scott Sicherer of Mt. Sinai Hospital in New York, urges clinicians to use caution when ordering allergy tests and to avoid making a diagnosis based solely on test results.

In an article, published in the January issue of Pediatrics, the researchers warn that blood tests, an increasingly popular diagnostic tool in recent years, and skin-prick testing, an older weapon in the allergist’s arsenal, should never be used as standalone diagnostic strategies. These tests, Sicherer and Wood say, should be used only to confirm suspicion and never to look for allergies in an asymptomatic patient.

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Do Educated Households Produce More Food Allergic Children?

Demographic Predictors of Peanut, Tree Nut, Fish, Shellfish, and Sesame Allergy in Canada

M. Ben-Shoshan et al

Journal of Allergy; Volume 2012 (2012), Article ID 858306, 6 pages

“[R]esults suggest that a higher educational level may be associated with an increased risk of food allergy. These results are consistent with other studies suggesting an increased risk for allergic diseases, including food allergies, in families with higher parental education. However, the mechanisms underlying these relationships are not yet well understood. Given that a higher education level may be associated with changes in family lifestyle, the hygiene hypothesis may partially account for these findings. Consistent with the hygiene hypothesis, smaller family size, decreased exposure to pets and livestock, fewer infections during infancy, increased use of antibiotics and vaccinations, and improved sanitation might decrease microbial burden and lead predominantly to a type 2 T-helper cell response which is responsible for triggering allergic disorders. Other factors may also explain this association between education and food allergy. It is possible that more educated parents may be more likely to have followed American Academy of Pediatrics’ recommendations regarding the restriction of potentially allergenic foods in early life. This guideline has recently been retracted as research suggests that delayed introduction may promote, rather than reduce, the development of food allergy. Further, educated parents have higher health literacy and may be more likely to consult a physician for suspected food allergies. Hence, the actual prevalence may not be higher in the more educated, but may merely appear increased because of greater likelihood of seeking a diagnosis.” [Emphasis added]

Cat Allergy Depends on When You Get the Cat

European researchers found that when adults get a cat for the first time, they stand a greater chance of allergies to cat dander than those who also had cats as children. The risk is lower if you had a cat as a child but higher if you already have some other allergies, according to Giuseppe Verlato, PhD, of the University of Verona in Verona, Italy, and colleagues.
On the other hand, adults who get a cat but don’t let it in the bedroom appear to be unlikely to become sensitized to the animal, Verlato and colleagues reported online in the Journal of Allergy and Clinical Immunology. The bottom line, the researchers concluded, is that “acquiring a cat increases the risk of cat sensitization in adulthood, particularly when the cat is allowed in the bedroom.”
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Low diversity of the gut microbiota in infants with atopic eczema

Thomas R. Abrahamsson, MD, PhD et al

Received 8 July 2011; received in revised form 12 October 2011; accepted 24 October 2011. published online 08 December 2011.

The diversity of microbes in a child’s gut is considered to be a key element in the subsequent development of allergic diseases.  This study seems to lend more support to this idea.

“Results
Infants with IgE-associated eczema had a lower diversity of the total microbiota at 1 month (P = .004) and a lower diversity of the bacterial phylum Bacteroidetes and the genus Bacteroides at 1 month (P = .02 and P = .01) and the phylum Proteobacteria at 12 months of age (P = .02). The microbiota was less uniform at 1 month than at 12 months of age, with a high interindividual variability. At 12 months, when the microbiota had stabilized, Proteobacteria, comprising gram-negative organisms, were more abundant in infants without allergic manifestation (Empirical Analysis of Digital Gene Expression in R [edgeR] test: P = .008, q = 0.02).
“Conclusion
Low intestinal microbial diversity during the first month of life was associated with subsequent atopic eczema.”

Study shows daily inhaled steroid no better than intermittent doses in preventing intermittent asthma exacerbations in small children

Daily inhaled glucocorticoids are recommended for young children at risk for asthma exacerbations. A study published in the New England Journal of Medicine, however, showed, “The daily regimen of budesonide did not differ significantly from the intermittent regimen with respect to the frequency of exacerbations, with a rate per patient-year for the daily regimen of 0.97 (95% confidence interval [CI], 0.76 to 1.22) versus a rate of 0.95 (95% CI, 0.75 to 1.20) for the intermittent regimen (relative rate in the intermittent-regimen group, 0.99; 95% CI, 0.71 to 1.35; P=0.60). There were also no significant between-group differences in several other measures of asthma severity, including the time to the first exacerbation, or adverse events.”

Conclusion: “A daily low-dose regimen of budesonide was not superior to an intermittent high-dose regimen in reducing asthma exacerbations. Daily administration led to greater exposure to the drug at 1 year.”

N Engl J Med 2011; 365:1990-2001November 24, 2011

More here.

How Are We Doing After Treating for Anaphylaxis? Terribly

National guidelines recommend that patients who go to the emergency department for food-induced anaphylaxis, a life-threatening event, should fill an epinephrine auto-injector prescription after discharge and follow up with an allergist. However, the record on compliance is terrible, according to a study called “A Retrospective Database Study of Concordance with Recommended Post-Discharge Anaphylaxis Care among US Adults Seen in the Emergency Department or Hospital with Food-Induced Anaphylaxis” (presented at the American College of Allergy, Asthma and Immunology Annual Meeting in Boston, Nov. 3-8).

In the first year after food-induced anaphylaxis, among 1,370 adults, researchers found just 55 percent filled an epinephrine autoinjector prescription and only 22 percent saw an allergist.

“It’s important for anyone who experiences anaphylaxis to follow up with an allergist to have the allergen identified, learn how to use self-injectable epinephrine and discuss scenarios when its use is needed,” says Carlos Camargo, MD, associate professor of Medicine, Harvard Medical School. “More research is needed to understand whether physicians need more education about anaphylaxis or if patients need interventions to ensure guidelines are followed. Either way, we need to improve anaphylaxis care to prevent future life-threatening reactions.”

(By the numbers: About 6 percent of young children and 3 to 4 percent of adults have food allergies in the United States. Every year between 150 and 200 people die as a result of food allergies.)

Allergy Shots More Effective at 1 Year for Pediatric Allergic Rhinitis Than Under-the-Tongue Immunotherapy, Study Shows

Research conducted in Turkey and published in the International Archives of Allergy and Immunology (Vol. 157, No. 3, 2012 ) comparing the efficacy of subcutaneous immunotherapy (SCIT) with sublingual immunotherapy (SLIT) for dust mites versus placebo concluded: “Based on the limited number of patients at the end of the 1-year immunotherapy, the clinical efficacy of SCIT on rhinitis and asthma symptoms was more evident when compared with the placebo.”

Sublingual immunotherapy is much more widely used in Europe than in the United States.

We discuss SLIT in Asthma Allergies Chidren: a parent’s guide:

“The idea of sublingual immunotherapy is attractive, especially for pediatric allergists. We would have to give fewer of those painful shots. There’s also the fact that it could be taken at home, which would save the health care system money.
There are two big drawbacks in the long run. First would be that we wouldn’t be in a position to monitor bad reactions. And the second is that left to their own devices, many patients wouldn’t follow their treatment… In the meantime, we have many decades of experience with subcutaneous injections. We know they work. Still, while SLIT remains a work in progress, it is worth pursuing.”

In addition, Dr. Chiaramonte points out that patients are reluctant to put one allergen in their mouths: cockroach extract. (For more on immunotherapy, click here.)

Oral food challenges (OFCs) can be safely done in a doctor’s office, but only by well-equipped, experienced doctors

According to a letter in the Journal of Allergy and Clinical Immunology, oral food challenges can be done in doctors’ offices if they are the right doctors with the right experience and the right equipment. “In the everyday clinical setting, the open, oral food challenge can be done safely and efficiently provided that it is carried out in patients selected based on favorable history and diagnostic testing and that it is performed in a physician’s office who is trained in recognizing allergic reactions, including anaphylaxis, and who is prepared in treating these possible reactions,” said first author Dr. Jay A. Liberman in an email to Reuters Health.

Dr. Liberman and colleagues at the Mount Sinai Medical Center in New York City reviewed data on 701 open OFCs with in 521 patients. “Performing these challenges in a general pediatrician’s office may be difficult given the time requirement (about one hour to perform the challenge and two hours post challenge for observation),” Dr. Liberman said. “However, they can be performed in any physician’s office provided the clinician: 1. Understands how to select for patients that have a favorable chance of passing the challenge based on the clinical history and past IgE testing (skin prick test and/or serum IgE testing); and 2. Is knowledgeable and prepared to diagnose and effectively treat any allergic reaction, including severe, systemic reactions. The clinician must have all emergency equipment available to treat a possible anaphylactic reaction.”

“Sensitization to food, as detected by positive skin prick testing or serum IgE levels, does not alone guarantee clinical reactivity or food allergy,” Dr. Liberman said. “One must consider the clinical history and testing together when deciding on a treatment plan.”

Researchers Ask: Is Sesame Seed the “Middle Eastern” Peanut?

An article in the Journal of the World Allergy Organization says: “Although speci?c IgE to peanut in infants, children, and adults were higher than for sesame, peanut-induced allergic reactions were mild, in contrary to sesame where anaphylaxis was the only clinical manifestation.” Sesame is a staple of Middle-Eastern diets. Tahini, which is made from sesame, is the foundation for such ubiquitous foods as hummus and baba ghanoush.

Authors Carla Irani, MD, George Maalouly, MD, Mirna Germanos, MD, and Hassan Kazma, MD conclude: “Further studies with double-blind, placebo-controlled food challenge are needed to establish the real prevalence of food allergy in Lebanon, and to determine the most common allergens taking in consideration the nutritional habits of our population.”
(WAO Journal 2011; 4:1–3)

Powder-free Environment Cuts Latex Allergy for Health Care Workers
Researchers at the Medical College of Wisconsin followed more than 800 health care workers at two hospitals in Wisconsin for 4.5 years, testing latex allergen in the air ducts of work areas before and after the switch to powder-free latex gloves. After the switch to powder-free latex gloves the team saw a 16-fold drop in the rate of latex allergy among the health care workers, and 25 percent of those with latex allergy at the start of study lost that sensitivity after the switch.

“This study provides the strongest evidence that allergic sensitivity to latex in health care workers is linked to airborne allergen exposure through powdered gloves,” lead author Dr. Kevin J. Kelly, professor of pediatrics (allergy/immunology), internal medicine, and vice chair in pediatrics, said in a college news release. Kelly’s team also found that workers who developed a sensitivity to latex were three times more likely to quit their job. The study, published online in the August issue of the Journal of Occupational and Environmental Medicine, received funding from the U.S. Centers for Disease Control and Prevention’s National Institute for Occupational Safety and Health.
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Anaphylaxis from Peanuts Ingested by Blood Donors?

N Engl J Med 2011; 365:867-868September 1, 2011
Jacobs et al. (May 19 issue)1 suggest that transfusion-related anaphylaxis occurred after passive transfer of peanut allergen to a sensitized person. There are at least two major problems with this conclusion. First, allergic transfusion reactions are relatively common and can be severe when platelets or other serum-rich products are used.2 Second, the transfused material was extensively analyzed, but there is no evidence that the platelets actually contained any allergen, even though a new enzyme-linked immunosorbent assay for the detection of peanut peptide is available. This assay was developed by one of the authors3 and cited in the letter. Using monoclonal antibodies and high-performance liquid chromatography, we and others have tried unsuccessfully to detect any circulating peanut protein in volunteers after very large ingestions (unpublished data). We therefore regard with skepticism the assumption that physiologically relevant contamination occurred, when only three of five donors consumed several handfuls of peanuts the night before donation.
Given that food allergy affects 4 to 6% of children in the United States, it is critical that the potential public health risk of allergen-contaminated blood products be clarified with rigorous study and not an unsubstantiated and speculative report.
Brian P. Vickery, M.D.
A. Wesley Burks, M.D.
Duke University School of Medicine, Durham, NC
brian.vickery@duke.edu
Hugh A. Sampson, M.D.
Mount Sinai School of Medicine, New York, NY

Nutrition: Breast-Feeding Does Not Prevent Eczema

By NICHOLAS BAKALAR
Prolonged breast-feeding is widely believed to protect infants against developing eczema and other allergic diseases. But a new study has found no evidence for the belief.

Even among children who had been breast-fed for six months or longer, there was no evidence that breast-feeding prevented eczema or limited its severity. The results were the same for children whose mothers had a history of allergy and for those who had a positive reaction to the allergens used in the skin-prick test.

“We’re not questioning the benefits of breast-feeding,” said Carsten Flohr, the lead author and a senior lecturer in pediatrics at Kings College London. “But when it comes to prevention of eczema, neither breast-feeding itself nor prolonged breast-feeding seems to be protective.”

The study appears online in The British Journal of Dermatology.

Only Half of Canadians With Food Allergies Have an Auto-Injector

Lianne Soller, Joseph Fragapane, Moshe Ben-Shoshan, Daniel W. Harrington, Reza Alizadehfar, Lawrence Joseph, Yvan St. Pierre, Samuel B. Godefroy, Sebastien La Vieille, Susan J. Elliott, Ann E. Clarke

“While it is recommended that because of the potential for anaphylaxis, all individuals with food allergy have an EAI, our results show that only 45% to 55% report having the device. On the basis of previous research by our group in school-age children reporting that less than 50% owning an EAI actually have it available at all times, we suspect that many of the 45% to 55% of respondents in SCAAALAR (Surveying Canadians to Assess the prevalence of common food Allergies and Attitudes towards food LAbelling and Risk) who own an EAI do not have it readily accessible.

“Individuals with food allergy who resided in a household where the primary respondent was married or living with a partner were more likely to own an EAI potentially because such households have higher health literacy and are more likely to seek appropriate medical attention and be more compliant with suggested management. It has been shown that single people are less likely to have a family doctor, making them less likely to consult a physician for a suspected food allergy and hence less likely to be prescribed an EAI. Furthermore, such households may be less able to afford the EAI.

“It was not surprising that children, individuals experiencing their most severe reaction at a younger age, and females were more likely to have an EAI. Parents are usually very diligent with their children’s health and would therefore ensure that they are properly assessed and managed for food allergy. As it is already known that males are less vigilant regarding their health, are less likely to have a family doctor, and are more likely to engage in risk-taking behaviors, it would be expected that they were less likely to have an EAI.”
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French Study Shows High Correlation Between Uncontrolled Asthma and Mood Disorder Among Teens
J Asthma. 2011 Aug;48(6):640-6. Epub 2011 May 25.
The association between asthma and anxiety disorders in teenagers is well documented, but data about the association with mood disorders are scarce. Researchers at Institut de Veille Sanitaire, Saint-Maurice , France analyzed data from ninth graders in 2003-2004. 7000 teenagers completed a self-administered questionnaire in which the occurrence of major depressive episodes (MDEs) during the past 12 months was assessed by the Composite International Diagnostic Interview-Short Form. Results. The prevalence of MDE during the past year was 14.2% in teenagers with current asthma versus 9.2% among the others. The association between current asthma and past-year MDE remained significant after adjustment for age, gender, family structure, and the father’s employment status. Asthma was uncontrolled (at least four attacks of wheezing, one awakening per week due to wheezing, one severe wheezing, four unplanned medical visits, or one hospitalization for a wheezing attack in the past year) in more than half (58.3%) of asthmatic teenagers with an MDE in the past year versus 35.3% of those without an MDE. Conclusion. Asthma is associated with a higher prevalence of MDE. Among adolescents with asthma, MDE is associated with poorer asthma control. These findings highlight the need for a comprehensive care management of asthma in France that takes the psychological dimension into account.
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Controller Medications Underused in Asthma Inpatients
Laurie Barclay, MD in MedScape

August 8, 2011 — Controller medications and follow-up are underused in young patients hospitalized for asthma, according to the results of a retrospective analysis of South Carolina Medicaid data from 2007-2009, reported online July 28 in Hospital Pediatrics. “Recommended preventive care following an asthma admission includes prescribing controller medications and encouraging outpatient follow-up,” write Annie Lintzenich, MD, from the Division of General Pediatrics at the Medical University of South Carolina in Charleston, and colleagues. “We sought to determine (1) the proportion of patients who receive controller medications or attend follow-up after asthma admission and (2) what factors predict these outcomes.”

Only half of patients received controller medications (52%) or attended follow-up appointments (49%), and less than one third (32%) received both controller medications and follow-up. “Patients with asthma admitted for acute exacerbations in South Carolina have low rates of controller medication initiation and follow-up attendance,” the study authors write. “Minority race/ethnicity patients are less likely to receive controller medications.”

“Pediatric hospital care providers are poised to contribute to the improved delivery of preventive care to hospitalized asthma patients,” the study authors conclude. “In accordance with the [Global Initiative for Asthma (GINA)] guidelines, we suggest uniform and more aggressive prescribing of controller medications at hospital discharge and, perhaps in the future, dispensing controller medications before discharge to eliminate barriers related to prescription filling. In addition, a focus on addressing health beliefs pertinent to chronic asthma care in a culturally competent manner will be vital to address the racial/ethnic disparities in preventive care delivery for hospitalized asthma patients.”
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Peanut Allergic Kids Who Outgrow Their Coexistent Asthma Still Show Elevated Airway Inflammation

Pediatr Allergy Immunol. 2010 Dec;21(8):1107-13. doi: 10.1111/j.1399-3038.2010.01071.x.
Peanut allergy and allergic airways inflammation.
Hughes JL, Brown T, Edgar JD, Shields MD.

“All children with outgrown asthma had elevated levels of FeNO (> 35 ppb), and 75% of children defined as ‘wheeze no treatment’ had elevated FeNO levels (> 35 ppb). Outgrown asthma and children defined as ‘wheeze no treatment’ had higher levels of FeNO than those with no history of wheeze or current treated asthma (p = 0.003). In children with peanut allergy, we found that those who had outgrown asthma had elevated FeNO levels in keeping with ongoing eosinophilic airways inflammation.”
Note: FeNO levels, considered a bio-marker for asthmatic inflammation, were measured with NIOX Mino, made by Aerocrine. Many doctors consider 25ppb the threshold of asthma.
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A novel approach in allergen-specific immunotherapy: Combination of sublingual and subcutaneous routes
Sevgi Keles, MD, Elif Karakoc-Aydiner, MD,Ahmet Ozen, MD, Ayse Gul Izgi, MS, Ayzer Tevetoglu, MS, Tunc Akkoc, PhD, Nerin N. Bahceciler, MD,Isil Barlan, MD

Sub-cutaneous immunotherapy plus sub-lingual with dust-mite allergic children appears promising seems to combine the advantages of the 2 alternatives: rapid onset and potency in SCIT and safety and avoidance of injections in SLIT.
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Delaying Emergency Department Visits for Asthma Results in Worse Outcomes
Carol Mancuso, MD, Hospital for Special Surgery, and Weill Cornell Medical College, presented findings on May 17 at the American Thoracic Society (ATS) 2011 International Conference showing that patients with uncontrolled asthma delay seeking ER care and may become so ill that they require hospitalisation.
The study of nearly 300 adult patients seen in the ER found that about half of patients (44%) had had symptoms for 2 to 5 days, and a third (34%) for more than 5 days before they arrived to the ER.

Although 80% of patients had a physician who handled their asthma, those who had had symptoms for the greatest amount of time were less likely to check in with their doctors before coming to the ER than those who had had symptoms for a shorter period (23% vs 18%), as well as use proven control drugs.
The results were exactly the opposite of what researchers expected to find. “We had anticipated that patients who waited longer and thus had more time would have been more likely to seek care from their regular doctors and would have used techniques to treat asthma that are known to be helpful,” said Dr. Mancuso.
Instead, the findings “emphasise that patients need to be taught how to gauge when exacerbations are serious and unlikely to get better with self management only.
[Presentation title: Prolonged Time Before Seeking Emergency Department Care for Asthma Results in Worse Outcomes. Abstract 3782]
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Vitamin D levels and food and environmental allergies in the United States: Results from the National Health and Nutrition Examination Survey 2005-2006
Shimi Sharief, MD, Sunit Jariwala, MD,Juhi Kumar, MD, MPH,Paul Muntner, PhD,Michal L. Melamed, MD, MHS
The Journal of Allergy and Clinical Immunology Volume 127, Issue 5 , Pages 1195-1202, May 2011

Previous research supports a possible link between low vitamin D levels and atopic disease. However, the association between low vitamin D levels and total and allergen-specific IgE levels has not been studied. Researchers sought to test the association between serum 25-hydroxyvitamin D (25[OH]D) deficiency (

The association of 25(OH)D deficiency with 17 different allergens was assessed after adjustment for potential confounders, including age; sex; race/ethnicity; obesity, low socioeconomic status; frequency of milk intake; daily hours spent watching television, playing videogames, or using a computer; serum cotinine levels; and vitamin D supplement use.

In children and adolescents allergic sensitization to 11 of 17 allergens was more common in those with 25(OH)D deficiency. Compared with sufficient vitamin D levels of greater than 30 ng/mL, after multivariate adjustment, 25(OH)D levels of less than 15 ng/mL were associated with peanut (odds ratio [OR], 2.39; 95% CI, 1.29-4.45), ragweed (OR, 1.83; 95% CI, 1.20-2.80), and oak (OR, 4.75; 95% CI, 1.53-4.94) allergies (P < .01 for all). Eight other allergens were associated with 25(OH)D deficiency, with P values of less than .05 but greater than .01. There were no consistent associations seen between 25(OH)D levels and allergic sensitization in adults.
Conclusion
Vitamin D deficiency is associated with higher levels of IgE sensitization in children and adolescents. Further research is needed to confirm these findings.
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The role of epigenetics in the developmental origins of allergic disease (Review of literature supports the idea that environment and diet can alter genes to produce allergic tendencies.)

Michelle L. North Bsc, Anne K. Ellis MD
Annals of Allergy, Asthma & Immunology Volume 106, Issue 5, Pages 355-361 (May 2011)
“There is increasing evidence pointing to the influence of prenatal and early life exposures on the development of allergic disease. A growing body of literature supports the theory that transient environmental pressures can have permanent effects on gene regulation and expression through epigenetic mechanisms. Histone modifications have been associated with degree of bronchial hyperresponsiveness and corticosteroid resistance in asthma. Epigenetic mechanisms can operate independently in various cell types; recent studies have suggested a role in the differentiation of human T cells. Murine studies have revealed that a maternal diet rich in methyl donors can enhance susceptibility to allergic inflammation in the offspring, mediated through increased DNA methylation. Murine studies have also implicated epigenetically modified dendritic cells in the transmission of allergic risk from mothers to offspring.”
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Review in Pediatrics affirms safety, efficacy of ICS
Inhaled Corticosteroids and Asthma Control in Children: Assessing Impairment and Risk
PEDIATRICS Vol. 123 No. 1 January 2009, pp. 353-366 (doi:10.1542/peds.2007-3273)

Gary Rachelefsky, MD, FAAP

The author reviewed, “A total of 18 placebo-controlled, clinical trials in >8000 children (aged 0–17 years) with asthma met the criteria for evaluating monotherapy with inhaled corticosteroids: 13 double-blind studies of inhaled corticosteroids versus placebo and 5 controlled studies that compared inhaled corticosteroids to a nonsteroid antiinflammatory agent. The findings can be summarized as follows: (1) Compared with placebo, inhaled corticosteroid treatment was associated with reductions in both the impairment and risk domains. (2) Improvements in impairment and risk observed with inhaled corticosteroids were generally greater than those observed with nonsteroid antiinflammatory comparator medications. (3) Inhaled corticosteroids were well tolerated. (4) Small reductions in growth rates were evident when compared with placebo and/or comparator nonsteroid antiinflammatory medication use in the long-term (>1-year) studies, but when measured, the reductions diminished with time.”
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Hookah Use Common Among College Students, Survey Finds
Many wrongly think water pipe use is safer than cigarettes, results from North Carolina show
FRIDAY, April 8 (HealthDay News) — Nearly one-fifth of U.S. college students who took part in a survey regularly use hookahs (water pipes), and many of them mistakenly believe that hookah smoking is safer than cigarette smoking.

The Internet-based survey sent to a random sample of students at eight North Carolina colleges and universities found that 40.3 percent reported having ever smoked tobacco from a hookah, nearly as many students (46.6 percent) who said they had ever smoked a cigarette. Nearly 25 percent of respondents said they were current users of cigarettes and 17.4 percent said they were current users of hookahs.

The investigators found that among those most likely to use hookahs were first-year students and males. In addition, the results suggested a link between use of hookahs, cigarettes and marijuana, a history of using illegal drugs, and alcohol use in the 30 days before the survey.

In general, hookah smokers tended to incorrectly believe that this activity was safer than cigarette smoking, according to the researchers at Wake Forest Baptist Medical Center. The study was released online in advance of publication in an upcoming print issue of the journal Drug and Alcohol Dependence.
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Asthma Care in Resource-Poor Settings
Sánchez-Borges, Mario MD; Capriles-Hulett, Arnaldo MD; Caballero-Fonseca, Fernan MD
World Allergy Organization Journal:
April 2011 – Volume 4 – Issue 4 – pp 68-72

Abstract
Asthma prevalence in low- to middle-income countries is at least the same or higher than in rich countries, but with increased severity. Lack of control in these settings is due to various factors such as low accessibility to effective medications, multiple and uncoordinated weak infrastructures of medical services for the management of chronic diseases such as asthma, poor compliance with prescribed therapy, lack of asthma education, and social and cultural factors. There is an urgent requirement for the implementation of better ways to treat asthma in underserved populations, enhancing the access to preventive medications and educational approaches with modern technological methods.

“In a study done in 24 developing countries in Africa and Asia, Edwards observed that oxygen was available in 50% of the clinics, electricity in 25 of 41 centers, peak flow meters only in 3 sites or 26 of 41 doctors, rapid-acting bronchodilators in all, inhaled corticosteroids in 50% (considered too expensive), and no offering of patient education.”
Link

Asthma Management Failure: A Flaw in Physicians’ Behavior or in Patients’ Knowledge?; Braido F, Baiardini I, Menoni S, Brusasco V, Centanni S, Girbino G, Dal Negro R, Canonica GW; Journal of Asthma (Mar 2011)

“The aim of this study was to explore general practitioners’ (GPs) behaviors, asthma patients’ knowledge requirements, and the relationship between physicians’ communicative issues, and failures in patients’ knowledge. Methods. GPs participating in a continuing medical education program on asthma completed an ad hoc survey on communicative style and recruited at least three adult asthma patients to indicate, among 10 options, three aspects of asthma about which they felt less informed…

“These results demonstrate that in general medicine the recommendations of international guidelines on education, communication, and development of a doctor-patient partnership are still ignored and that patients’ educational priorities may differ from those identified by medical specialists and by patients belonging to patients’ associations.”
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JACI Issue Concentrates on Food Allergy

This month’s issue of the Journal of Allergy and Clinical Immunology is devoted to recent advances in food allergy, following up the publication last year of the NIAID guidelines. “The current theme issue builds on the recognition of food allergy as a significant public health problem by examining issues related to the epidemiology, risk factors, mechanisms, and new treatments on the horizon for this common problem seen by both allergists and primary care providers.”
“Conclusion and future directions
“There are few diseases that spark more debate regarding causation or diagnostic criteria than food allergy. The commitment by federal agencies and various foundations to fund more research in food allergy is a big step forward toward developing an effective treatment for this common, potentially life-threatening condition that can significantly affect the lives of patients and their families. Favorable results involving oral and sublingual immunotherapy to specific food allergens as well as clinical trials with anti-IgE and a Chinese herbal formulation provide optimism that we are closer to a “cure” for food allergy. However, different patterns of response to the various treatments, including subsets of patients who lack benefits, suggest the need for more careful identification of patients likely to benefit from each form of therapy. Before these treatments can be used in clinical practice, additional studies are needed to determine optimal maintenance doses, ideal duration, degree of protection, efficacy for different ages, severity and type of food allergies responsive to treatment. In addition, questions remain about long-term safety and mechanisms by which the different treatments work. However, the current theme issue strongly suggests that the field of food allergy is poised for clinically important advances.”
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Study in New England Journal of Medicine Says Xolair Very Effective for Asthma Among Inner-City Kids

Before: the children were having asthma symptoms an average of 1.96 days during a two-week period. After: those who received omalizumab saw the duration of their symptoms drop to 1.48 days per two week period, a reduction of 24.5 percent.
Those taking long-term preventive medications were able to reduce the amount of medication without experiencing an increase in symptoms. The treatment group had a 75 percent reduction in the number of hospitalizations compared to the placebo group.
Exacerbations in the omalizumab group were reduced — 30.3 percent vs. 48.8 in the placebo group. The omalizumab group didn’t experience seasonal peaks in their asthma symptoms, which normally happens in the spring and the fall.

“Conclusions
“When added to a regimen of guidelines-based therapy for inner-city children, adolescents, and young adults, omalizumab further improved asthma control, nearly eliminated seasonal peaks in exacerbations, and reduced the need for other medications to control asthma. (Funded by the National Institute of Allergy and Infectious Diseases and Novartis; ClinicalTrials.gov number, NCT00377572.)”
More here and here
Note: Back in October, we had a three-doctor “roundtable” on Xolair in response to the British National Health Service’s refusal to cover it for children. Read about it here.

Decreased response to inhaled steroids in overweight and obese asthmatic children
Erick Forno, MD, MPH, Rachel Lescher, MD, Robert Strunk, MD, Scott Weiss, MD, MS, Anne Fuhlbrigge, MD, MPH, Juan C. Celedón, MD,

Conclusions
Compared with children of normal weight, overweight/obese children in the Childhood Asthma Management Program showed a decreased response to inhaled budesonide on measures of lung function and emergency department visits/hospitalizations for asthma.
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Findings on Pollution Damage to Human Airways Could Yield New Therapies
Jinju Li, Patrick Kanju, Michael Patterson, Wei-Leong Chew, Seung-Hyun Cho, Ian Gilmour, Tim Oliver, Ryohei Yasuda, Andrew Ghio, Sidney A. Simon, Wolfgang Liedtke. TRPV4-Mediated Calcium-influx into Human Bronchial Epithelia upon Exposure to Diesel Exhaust Particles. Environmental Health Perspectives, 2010; DOI: 10.1289/ehp.1002807
ScienceDaily (Jan. 18, 2011) — Researchers from Duke University Medical Center have identified how nanoparticles from diesel exhaust damage lung airway cells, a finding that could lead to new therapies for people susceptible to airway disease.
The scientists also discovered that the severity of the injury depends on the genetic make-up of the affected individual.
“We gained insight into why some people can remain relatively healthy in polluted areas and why others don’t,” said lead author Wolfgang Liedtke, M.D., Ph.D., assistant professor in the Duke Department of Medicine and an attending physician in the Duke Clinics for Pain and Palliative Care.
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3-D Model Will Help Develop Better Asthma Therapies

N. C. Gilbert, S. G. Bartlett, M. T. Waight, D. B. Neau, W. E. Boeglin, A. R. Brash, M. E. Newcomer. The Structure of Human 5-Lipoxygenase. Science, 2011; 331 (6014): 217 DOI: 10.1126/science.1197203

LSU graduate student Nathanial Gilbert and Professor of Biological Sciences Marcia Newcomer, together with Associate Professor Sue Bartlett, have developed the first 3-D model of Human 5-Lipoxygenase, or 5-LOX, the molecule responsible for creating inflammatory compounds that provoke asthma. This model will serve as a target for the design of new, more effective asthma medication.

Their research was printed in Science on Jan. 14 and was the subject of an article in Science Translational Medicine.
“This molecule is responsible for starting the synthesis of compounds referred to as ‘signaling molecules,’ which cause inflammation,” said Newcomer. “If we can look at this molecule in closer detail than we have previously been able to do so, then that will allow for the development of better asthma medications that are able to stop an attack more effectively.”
Prior to their development, scientists had been unable to study this molecule in detail because of its transient nature.
“It was really hard to work with,” said Newcomer. “5-LOX is unstable. Before you could start your experiments, the enzyme would self-destruct.”
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Diet and Asthma: Nutrition Implications from Prevention to Treatment
Keith Allan MSc and Graham Devereux MD, PhD
Journal of the American Dietetic Association
Volume 111, Issue 2, February 2011, Pages 258-268
Currently there is insufficient evidence to support the use of nutrient supplements to complement conventional treatment; however, results of ongoing studies are awaited, and additional research is required, particularly in children.
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Exposure to Environmental Microorganisms and Childhood Asthma
Markus J. Ege, M.D., Melanie Mayer, Ph.D., Anne-Cécile Normand, Ph.D., Jon Genuneit, M.D., William O.C.M. Cookson, M.D., D.Phil., Charlotte Braun-Fahrländer, M.D., Dick Heederik, Ph.D., Renaud Piarroux, M.D., Ph.D., and Erika von Mutius, M.D. for the GABRIELA Transregio 22 Study Group
N Engl J Med 2011; 364:701-709February 24, 2011
Conclusions
Children living on farms were exposed to a wider range of microbes than were children in the reference group, and this exposure explains a substantial fraction of the inverse relation between asthma and growing up on a farm. (Funded by the Deutsche Forschungsgemeinschaft and the European Commission.)
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Cough Variant Asthma and the Progression to “Classic” Asthma

“Cough is the most common complaint for which patients seek medical attention. Cough variant asthma (CVA) is a form of asthma, which presents solely with cough. CVA is one of the most common causes of chronic cough. More importantly, 30 to 40% of adult patients with CVA, unless adequately treated, may progress to classic asthma. CVA shares a number of pathophysiological features with classic asthma such as atopy, airway hyper-responsiveness, eosinophilic airway inflammation and various features of airway remodeling. Inhaled corticosteroids remain the most important form of treatment of CVA as they improve cough and reduce the risk of progression to classic asthma most likely through their prevention of airway remodeling and chronic airflow obstruction.”
Abstract here

Combination Rescue Medications Best for Asthma
Asthmatic children had fewer exacerbations and significantly fewer treatment failures with combination rescue therapy — an inhaled corticosteroid and albuterol — according to results of a randomized trial.
The trial, conducted among almost 400 children and adolescents, found that rescue treatment with beclomethasone plus albuterol reduced the frequency of exacerbations by 35% and the rate of treatment failure by more than 60% compared with placebo, Fernando D. Martinez, MD, of the University of Arizona in Tucson, and colleagues reported.
While two regimens of daily beclomethasone also lessened exacerbations and treatment failures compared with placebo, both regimens were associated with growth inhibition — whereas rescue beclomethasone was not, Martinez and colleagues wrote online in The Lancet.
“Children with mild persistent asthma should not be treated with rescue albuterol alone, and the most effective treatment to prevent exacerbations is daily inhaled corticosteroids,” the group concluded.
“Inhaled corticosteroids as rescue medication with albuterol might be an effective step-down strategy for children with well controlled mild asthma because it is more effective at reducing exacerbations than is use of rescue albuterol alone,” they wrote. “Use of daily inhaled corticosteroid treatment and related side effects, such as growth impairment, can therefore be avoided.”
Daily inhaled corticosteroids effectively control mild, persistent asthma, but some children continue to have exacerbations, even with good daily control. Additionally, many patients discontinue inhaled corticosteroids after they become asymptomatic, the authors wrote in their introduction.
The findings have potentially major implications for asthma management in children, given that U.S. and British clinical guidelines recommend daily inhaled corticosteroids as initial and step-up treatment for persistent asthma, William Checkley, MD, of Johns Hopkins University, wrote in a commentary. Step-down therapy is possible after symptoms have been controlled for three months.
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Nasal congestion, a sign of severe asthma
A study from the Sahlgrenska Academy’s Krefting Research Centre suggests that nasal congestion can be a sign of severe asthma.

The population study included 30,000 randomly selected participants from the west of Sweden and asked questions about different aspects of health.

“This is the first time that the prevalence of severe asthma has been estimated in a population study, documenting that approximately 2pc of the population in the West Sweden is showing signs of severe asthma,” said Jan Lotvall, one of the authors of the study and professor at the Sahlgrenska Academy”s Krefting Research Centre.

“This argues that more severe forms of asthma are far more common than previously believed, and that healthcare professionals should pay extra attention to patients with such symptoms. We also found that more pronounced nasal symptoms, such as chronic rhinosinusitis, in other words nasal congestion and a runny nose for a long period of time, can be linked to more severe asthma.”

Lotvall suggests that patients who report nasal complaints, perhaps together with minor symptoms from the lower respiratory tract, such as wheezing, shortness of breath during physical effort, and night-time awakings because of breathing problems – should be investigated for asthma.

The study has been published in the online scientific journal Respiratory Research.
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{Note: Readers of Asthma Allergies Children: a parent’s guide will know that we place great emphasis on the connection between the sinuses and the lungs. We call it, “One Airway, One Disease.”

Reliance on Alternative Treatment Associated with Doubling of Uncontrolled Asthma

A study from Universite de Montreal, published in the Canadian Respiratoy Journal, has suggested that approximately 13 per cent of parents turn to alternative therapies to treat their children’s asthma suggesting an association with a two-fold higher rate of poor asthma controlinchildren.

“Previous studies have shown that close to 60 per cent of parents believe that complementary and alternative medicines are helpful. Yet, well designed studies have failed to show any evidence that therapies such as acupuncture, homeophathy, chiropractic medicine or herbal therapy are effective in asthma,” said senior author Francine M. Ducharme, a Universite de Montrealprofessor.

“Parents may not be aware of the risk associated with the use of alternative medicine, including adverse reactions, possible interactions with conventional asthma therapy, as well as delay in taking, and compliance with, effective asthma therapy. Our findings confirm that children using complimentary or alternative medicine, are twice as likely to have poor asthma control that those that don’t,” he added.

More than 2000 families, who came to the Asthma Centre at the Montreal Children’s Hospital for an initial visit, completed questionnaires. Parents were asked if they used any form of alternative medicine to help alleviate their children’s asthma and to specify which type.

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Border Patrol: Immune Cells Protect Body from Invaders
ScienceDaily (Feb. 9, 2011) — So-called barrier sites — the skin, gut, lung — limit the inner body’s exposure to allergens, pollutants, viruses, bacteria, and parasites. Understanding how the immune system works in these external surfaces has implications for understanding such inflammatory diseases as asthma, psoriasis, IBD, and food allergies, all of which occur at the body’s barriers.
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Brain Tumor Risk Drops With More Allergies
By Todd Neale, Staff Writer, MedPage Today
Published: February 07, 2011
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

There may be one benefit to having a lot of allergies — they may protect against glioma, researchers found.
Patients with gliomas were significantly less likely to report having any allergy (OR 0.60, 95% CI 0.46 to 0.79), a relationship that applied to both high- and low-grade tumors, Bridget McCarthy, PhD, of the University of Illinois at Chicago, and colleagues reported in the February issue of Cancer Epidemiology, Biomarkers & Prevention.
In fact, patients who had more types of allergies — seasonal, medication, pet, food, and other — had even lower odds of glioma, with an 11% reduction for those with allergies in one category and a 64% reduction for those with allergies in four or more categories (P The findings are compatible with previous studies, which have consistently observed an inverse relationship between allergies and the risk of brain tumors.
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The Madison Avenue effect: How drug presentation style influences adherence and outcome in patients with asthma
Emmanuelle M. Clerisme-Beaty, MD, MHSSusan J. Bartlett, PhDW. Gerald Teague, MDJohn Lima, PharmDCharles G. Irvin, PhDRubin Cohen, MDMario Castro, MD, MPHRobert A. Wise, MDCynthia S. Rand, PhD
Conclusion
“The use of an enhanced presentation aimed at increasing outcome expectancy may lead to improved medication adherence.”
The Journal of Allergy and Clinical Immunology
Volume 127, Issue 2 , Pages 406-411, February 2011

Surveillance of the cost of asthma in the 21st century

Peter J. Gergen, MD, MPH

“Does increasing expenditures on medication necessarily translate into better care? Unfortunately, this report shows there is still much morbidity remaining. Adults with asthma were found to have more activity limitations than nonasthmatic subjects. Activity limitations among asthmatic subjects are usually due to lack of asthma control. The findings of this report are consistent with other work, showing that asthma is still not well controlled in the United States. For example, a recent provider-based study estimated that 58% of adult asthma is uncontrolled. With spending on medication increasing, why is asthma control not better? To control asthma, a patient must not only have access to a medication but also know how and when to use it. In addition, environmental interventions must be implemented to reduce exposure to asthma triggers, such as cigarette smoke and environmental allergens, to increase our chance of controlling asthma. Are we spending enough on asthma education and environmental remediation? Present monitoring systems cannot tell us the answer to this important question.”
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Specific immunotherapy in asthma: efficacy and safety
G. Passalacqua, G. W. Canonica
“Both SLIT and SCIT can be used in asthma associated with rhinitis (which is the most common condition), provided that asthma is adequately controlled by pharmacotherapy. In such case, a measurable clinical benefit on asthma symptoms can be expected. On the other hand, SIT cannot be presently recommended as single therapy when asthma is the unique manifestation of respiratory allergy.”
Clinical & Experimental Allergy
Article first published online: 24 JAN 2011
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Yale Study Links Early Antibiotic Use and Asthma

“We conclude that antibiotic exposure before 6 months of age is associated with asthma and allergy at 6 years of age and that protopathic bias is unlikely to account for the main findings. The adverse effect of antibiotics on asthma risk was particularly strong in children with no parental history of asthma, which should encourage physicians to avoid unnecessary antibiotic use in low-risk children with no genetic predisposition to asthma.”
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Worms and Hygiene Hypothesis; Prenatal Exposure May Protect Against Eczema

Exposure to worm infections in the womb may protect a newborn infant from developing eczema, a study funded by the Wellcome Trust suggests. Research in Uganda showed that treating a pregnant woman for worm infections increased her child’s chances of developing the allergic skin disease.
Published this week in the journal Pediatric Allergy and Immunology, the research supports the so-called ‘hygiene hypothesis’, which proposes that exposure to infections in early childhood can modify the immune system and protect the child from allergies later in life.
The World Health Organisation estimates that one in five of the world’s population suffers from allergic diseases such as asthma and eczema, but this epidemic is no longer restricted to developed countries: more than four out of five deaths due to asthma occur in low and lower-middle income countries. The declining incidence and prevalence of infectious diseases — including chronic infection by worms known as helminths — is widely considered to be an important contributor contributing to this increase.
Helminth infection can cause symptoms ranging from mild anaemia through to stomach pain and vomiting, depending on how intense the infection is, but very often people have no symptoms at all. The parasitic worms tend to enter the body through contaminated food or water, mosquito bites or through walking in bare feet on contaminated soil.
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Antibiotics use in babies may increase childhood asthma risks
When babies are given antibiotics, their risk of developing asthma by age 6 may increase by as much as 50 percent. ??
The relationship between antibiotic use in babies less than six months old and risk of developing asthma has been clearly documented in a study conducted by Norwegian University of Science and Technology (NTNU) researcher Kari Risnes.
The research was conducted while Risnes was a visiting researcher at Yale University, and the recent online publication of the article in the American Journal of Epidemiology has received considerable attention in the United States.
“Asthma is a very common disease. At the same time, about one-third of infants in our study were treated with antibiotics by the time they were six months old. This proportion is about 30 per cent in other Western countries,” says Risnes.
The Yale study followed 1400 children and mothers from the beginning of pregnancy until the children were six years old. ??“We found that the risk that children would have asthma as six year olds was 50 per cent higher when they had been given antibiotics as a baby. That is a significant increase,” she says.
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Full paper here

Second-Hand Smoke; First-Hand Sickness and Death

In the first comprehensive study on the toll that second-hand smoke takes on health worldwide, Swedish researchers compiled some alarming (but unsurprising) statistics. In 2004 (it takes that long to analyze this much data), 603,000 deaths could be attributed to second-hand smoke, 1% of all deaths that year. Of these, 36,900 of them were from asthma. Women were the victims 47% of the time, 28% were children, and 26% were men. By another measure, asthma cost adults 1,246,000 disability-adjusted life-years, or DALYs, and children lost 651,000.
This study was published in The Lancet/vol. 377, January 8, 2011.
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New CDC statistics show asthma causes thousands of deaths, nearly 2 million emergency room visits annually. Asthma prevalence higher among females, children, African-Americans, Puerto Ricans, people living below the poverty level, and residents of the Northeast and Midwest.
According to the report:
• 8.2% of the U.S. population has asthma, or about 24.9 million people.
• That total includes 17.5 million adults and 7.1 million children.
• In 2008, a preliminary estimate of 3,395 asthma deaths were reported, down slightly from 3,447 in 2007.
• The disease accounted for 10.5 million lost school days and 14.2 million lost work days in 2008.
• About 1.75 million people went to emergency rooms for asthma treatment in 2007, and 456,000 were hospitalized and discharged after being treated for asthma.
• Nearly 14 million people visited private doctor’s offices for asthma treatment in 2007.
• 4.2% of the population in 2009 reported at least one asthma attack in the previous year, or 52% of people with current asthma.
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Canadian study links asthma management, socioeconomic status, and medication insurance characteristics to exacerbation frequency in children with asthma
Wendy J. Ungar, et al

Younger age, previous emergency visits, nebulizer use, pet ownership, and receipt of asthma education but not an action plan were significantly associated with more frequent exacerbations. In the full cohort, children with high income adequacy had 28% fewer exacerbations than did children with low income adequacy. In the subgroup with drug insurance, girls had 26% fewer exacerbations than did boys, and children with food, drug, or insect allergies had 52% more exacerbations than did children without allergies. Children of families with annual insurance deductibles greater than $90 had 95% fewer exacerbations. Every percentage increase in the proportion of income spent out-of-pocket on asthma medications was associated with a 14% increase in exacerbations.
Conclusions
Asthma history, disease management factors, and SES were associated with exacerbations requiring urgent care. In families with drug plans, the magnitude of asthma medication cost-sharing as a proportion of household income, rather than income alone, was significantly associated with exacerbations.
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Translation of a Pediatric Asthma-Management Program Into a Community in Connecticut
Michelle M. Cloutier, MDa,b, Dorothy B. Wakefield, MSb

Pediatrician’s offices from 6 communities in Connecticut were trained in specific asthma-management services for children aged 6 months or older. Quality measures included enrollment numbers, appropriate use of anti-inflammatory therapy, and distribution of a written treatment plan.
RESULTS A total of 51 practices and 297 clinicians enrolled 32 680 children from 2002 to 2007; 10 467 had asthma, of whom 4354 were insured with Medicaid. Children with persistent asthma experienced decreases in the number of hospitalizations and emergency-department visits, and there was no change in number of outpatient visits. Inhaled corticosteroid use doubled, appropriate use of anti-inflammatory therapy increased to 96%, and 94% of the children were given a written treatment plan.
CONCLUSIONS General pediatricians can successfully implement an asthma-management program that is effective in improving care for large numbers of children.
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Omalizumab (Xolair) treatment shown to increase exercise capacity in severe asthmatics. Read more here.

Poor People Suffer From Asthma More Than Those With Higher Living Standards

The report from the UCLA Center for Health Policy Research found that of the more than 600,000 Californians who experience frequent — daily or weekly — symptoms that can signal uncontrolled asthma, a significant proportion (39.1 percent) earn less than 200 percent of the federal government’s poverty standard (FPL). The report’s authors also found a relationship between poverty and a lack of access to quality health care and repeated exposure to environmental triggers for asthma symptoms, such as smoking and second-hand smoke. Those counties with a high percentage of families living in poverty had some of the highest proportions of people currently suffering from asthma. In all counties, however, poverty was associated with asthma.

“The poorest among us suffer most because they lack quality health care and live in high-risk environments,” said Ying-Ying Meng, a senior research scientist with the center and co-author of the report.

“That disparity also burdens our health system with costly emergency care and hospitalizations and extracts the additional high cost of millions of lost days of work and school. Asthma has the potential to be debilitating,” Meng added, “but it can be effectively controlled through appropriate medical care and avoidance of triggers,” Meng said.
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School-Based Intervention Makes Huge Gains in Asthma Control

A school-based 8-week intervention program helped New York City high school students with moderate to severe asthma reduce acute medical visits by 28%, emergency department visits by 49% reduction in, and hospitalizations by 76% compared with asthmatic students who did not participate. The program participants also experienced a 31% reduction in night awakenings, and a 42% reduction in activity restriction due to asthma, according to the study. The study was reported in the American Journal of Respiratory and Critical Care Medicine.

“The program helps teach adolescents the steps they can take to gain control of their symptoms, and learn about treatment options,” says co-author Jean-Marie Bruzzese, PhD, assistant professor of child and adolescent psychiatry at NYU Langone Medical Center. “We found that it was effective in improving asthma self-management, reducing night wakening due to symptoms and the need for urgent healthcare in low-income, urban minority adolescents,” she says.

The program, called the Asthma Self-Management for Adolescents (ASMA), helped adolescents learn key facts about their disease, dispelled myths about medication, and showed how to better manage asthma using medication and controlling environmental triggers, according to the study.
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Under-the-Tongue: Sublingual Immunotherapy Gains Momentum

Expanded trials in the U.K. for Sublingual Immunotherapy (SLIT) have shown its efficacy. Immunotherapy given as pills or drops under the tongue is a safe and effective way to treat hayfever-like allergies caused by pollen and dust mites, according to a new Cochrane Systematic Review. The researchers say the approach is an attractive alternative to immunotherapy injections in children.

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Exposure to Farm Animals During Pregnancy May Reduce Child Skin Allergies
The Journal of Allergy & Clinical Immunology (JACI) has published a study by Caroline Roduit from the research team of Roger Lauener, University of Zurich. The study analyzes how prenatal environmental factors and genetic mechanisms influence the development of atopic dermatitis during the first two years of life. The authors of the study examined children in rural areas of five European countries: Austria, Finland, France, Germany and Switzerland. Of the 1,063 children taking part in the study, 508 were from families that lived on farms, 555 were not farm children.
The researchers were able to demonstrate that women who spend their pregnancy in the proximity of farm animals and cats have children with a reduced risk of developing atopic dermatitis in their first two years of life.
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Financial barriers may be increasing the number of visits to the emergency room for kids with asthma
A new Canadian study reveals that financial barriers – in the form of sharing asthma medication costs between insurers and families, are contributing to poor asthma control in children. Findings are published in a recent edition of Annals of Allergy, Asthma & Immunology.
The study looked at data from 490 Toronto-area children with asthma. Children aged one to 18 years were enrolled between November 2000 and March 2003 and were followed for one year. A highly significant finding in the sub-group of drug plan holders was that for every one per cent increase in family income spent out-of-pocket on a child’s asthma medications, there was a 14 per cent increase in the number of severe asthma attacks resulting in an emergency room visit or hospital admission.
“It was concerning to see that as parents faced higher out-of-pocket costs for their child’s asthma medications, severe asthma attacks increased,” says Ungar, who is also an AllerGen NCE investigator. “Understanding the health impact of financial barriers, in the form of deductibles and co-payments, is critical evidence in the formulation of effective drug policy as drug plans increasingly seek ways to contain costs while preserving patient health.”
The research team found the following factors were significantly associated with more frequent asthma attacks requiring urgent care: i) younger age; ii) previous emergency visits; iii) nebulizer use; iv) pet ownership and v) having asthma education, but no management or action plan. Having an asthma action plan was found to significantly reduce the number of severe asthma attacks. Also, children from families with high income adequacy, a measure that combines household income with family size, had 28 per cent fewer severe asthma attacks than children with low income adequacy.
In addition to the effects above, the scientists looked at a sub-group within the data sample all of whom had drug insurance and found that:
• Girls had 26 per cent fewer exacerbations than boys,
• Children with food, drug or insect allergies had 52 per cent more severe asthma attacks than children without allergies,
• Children of families with annual insurance deductibles greater than $90 had 95 per cent fewer exacerbations.
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Nasal symptoms and severe asthma connected?
A study reveals a connection between nasal symptoms and severe asthma
Investigators from the University of Gothenburg performed a large survey in West Sweden and found that the prevalence of asthma is high there – approximately 8.5%, but this rate has been stable over the last two decades. Researcher Jan Lötvall said, “Individuals reporting multiple asthma symptoms are likely to have a more severe form of asthma, which has been shown to increase the risk of asthma attacks, increases health care utilization and negatively influence quality of life”.
The study indicates that risk of having asthma with multiple symptoms could increase in those patients who experience blocked & runny nose. Further, signs of chronic rhinosinusitis (symptoms of which include nasal blockage, runny nose, lack of smell and/or pain from sinuses over at least 12 weeks) increases the risk of severe asthma. A one-of-its-kind research, the study is based on an epidemiological cohort which indicates a close relationship between severe nasal symptoms and asthma.
According to Lötvall, “Our study strongly supports the concept that nasal disease and asthma often are closely related, and argues that doctors should consider whether asthma patients with symptoms from the nose have severe asthma, possibly requiring more intense intervention”.
The study results have paved way for further research that will enable doctors to understand the intricacies of asthma and its relation with nasal symptoms.
Link
(Note: The connection between allergic rhinitis and asthma is fully explained in chapter 4, Asthma Allergies Children: a parent’s guide in the section “One Airway, One Disease.” The normal filtering mechanism performed by a clear nose and upper airways isblocked, trapping allergens and exacerbating underlying inflammation.)

Effects of Food Insecurity on Asthma Outcomes in the Pediatric Emergency Department
Hendrickson, Marissa A. MD*†; O’Riordan, Mary Ann MS‡; Arpilleda, Joyce C. MD†‡§?; Heneghan, Amy M. MD‡¶

Researchers studied the correlation of food insecurity with asthma exacerbations leading to visits to emergency rooms.
“Results: A total of 127 families were enrolled, with a median patient age of 6.6 years. Of all families, 81% were black and 10% were white. Of these families, 35% met criteria for household food insecurity. 78% of food-insecure and 46% of food-secure households received food stamps. Of all food-insecure households, 67% reported never using food pantries or free community meals. 36% of food-insecure and 31% of food-secure patients lacked an adequate home supply of asthma medications. The overall admission rate was 37%; no significant difference was found in admission rate or length of stay.
“Conclusions: The rate of household food insecurity in families of asthmatic children presenting to an urban ED is high, with relatively low participation in a number of safety net programs. This study failed to demonstrate an association between household food insecurity and negative asthma outcomes.”
Link

Food-Allergy Fears Drive Overly Restrictive Diets, Study Suggests
ScienceDaily (Nov. 4, 2010) — Many children, especially those with eczema, are unnecessarily avoiding foods based on incomplete information about potential food-allergies, according to researchers at National Jewish Health. The food avoidance poses a nutritional risk for these children, and is often based primarily on data from blood tests known as serum immunoassays.
Many factors, including patient and family history, physical examination, and blood and skin tests, should be used when evaluating potential food allergies. The oral food challenge, in which patients consume the suspected allergenic food, is the gold standard test.
The researchers conducted a retrospective chart review of 125 children evaluated at National Jewish Health for suspected food allergies. Depending on the reason for food avoidance, 84 percent to 93 percent of foods being avoided were restored to their diets after an oral food challenge. The researchers published their study online in The Journal of Pediatrics on Oct. 29. It will appear in a later print version of the journal. “People with known food allergies, especially those with a history of anaphylactic reactions, should by all means avoid those foods,” said David Fleischer, MD, lead author of the study and Assistant Professor of Pediatrics at National Jewish Health. “However, a growing number of patients referred to our practice are being placed on strict, unproven food-elimination diets that have led to poor weight gain and malnutrition. These overly restrictive diets have been chosen for a variety of reasons, but overreliance on immunoassay tests appears to be the most common cause.”
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Asthma Attacks From Allergies Send Kids to ICU
Study Shows Allergy-Induced Asthma Attacks Raise Odds of Treatment in Intensive Care Units
By Bill Hendrick
WebMD Health News

Children whose asthma attacks are triggered by allergic reactions are much more likely to wind up being treated in intensive care units for severe symptoms of the lung disease, a new study shows.
Also, children admitted to intensive care units had been sick for significantly shorter periods before being admitted to the hospital, the researchers say.
Seasonal Changes
factor in the severity of asthma attacks.
In both August and October, children were much more likely to be admitted to the intensive care unit vs. the hospital ward than in other months.
The researchers conclude that allergic reactions, perhaps triggered by seasonal changes, may increase the incidence of admissions for asthma attacks to intensive care units.
About 10,000 children a year in the U.S. are treated for asthma in intensive care units.
The study is being presented during CHEST 2010, the American College of Chest Physicians’ annual meeting that runs through Nov. 4 in Vancouver, British Columbia, Canada.
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Pregnant Women Who Eat Peanuts May Put Infants at Increased Risk for Peanut Allergy, Study Finds
ScienceDaily (Nov. 1, 2010) — Researchers have found that allergic infants may be at increased risk of peanut allergy if their mothers ingested peanuts during pregnancy.
The data are reported in the November 1 issue of the Journal of Allergy and Clinical Immunology.
Led by Scott H. Sicherer, MD, Professor of Pediatrics, Jaffe Food Allergy Institute at Mount Sinai School of Medicine, researchers at five U.S. study sites evaluated 503 infants aged three to 15 months with likely milk or egg allergies or with significant eczema and positive allergy tests to milk or egg, which are factors associated with an increased risk of peanut allergy. The study infants had no previous diagnosis of peanut allergy. A total of 140 infants had strong sensitivity to peanut based on blood tests, and consumption of peanut during pregnancy was a significant predictor of this test result.
“Researchers in recent years have been uncertain about the role of peanut consumption during pregnancy on the risk of peanut allergy in infants,” said Dr. Sicherer. “While our study does not definitively indicate that pregnant women should not eat peanut products during pregnancy, it highlights the need for further research in order make recommendations about dietary restrictions.”
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What can country of birth tell us about childhood asthma?

BOSTON (October 25, 2010) — Researchers from Tufts University pooled data from five previous epidemiological studies to investigate the prevalence of asthma in children in the Boston neighborhoods of Chinatown and Dorchester. Among children born in the United States, low socioeconomic status (SES) and exposure to pests (mice and cockroaches) were both associated with having asthma. Neither association was present in children born outside of the United States. The study was published online in advance of print in the Journal of Immigrant and Minority Health.
“In earlier studies, we found that country of birth was associated with asthma risk, which led us to the current analyses. Our current findings may help bring a new perspective to asthma research as they highlight the importance of studying foreign-born children. Much of the existing research follows U.S.-born children from birth to see if, and potentially why, they develop asthma. It might add to our understanding of what causes asthma if we knew why foreign-born children seem to be less likely to develop asthma,” said Doug Brugge, PhD, MS, senior author and professor of public health and community medicine at Tufts University School of Medicine. Brugge co-authored the five previous studies that were analyzed for this study.
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Early Pregnancy in Spring Linked to Child’s Susceptibility to Food Allergies, Finnish Study Suggests
ScienceDaily (Oct. 20, 2010) — A child’s likelihood of developing food allergies can be traced back to the season during which he or she completes their first three months of life in the womb, suggests research published online in the Journal of Epidemiology and Community Health.
Finnish researchers found that up to the age of 4, the incidence of an allergic response to certain foods varied according to season of birth, ranging from 5% for children born in June/July to 9.5% for those born in October/November. Around one in 10 (11%) children, whose 11th week of development in the womb had occurred during April or May were sensitized to food allergens, compared with a rate of 6% among children who reached that stage of fetal development in December/January.
Readings of ambient pollen for the years in question showed that levels of birch and alder pollen peaked during April and May.
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Allergic rhinitis alone or with asthma is associated with an increased risk of sickness absences
Paula Kauppia, Paula Salob, Riina Hakolab, Jaana Penttib, Tuula Oksanenb, Mika Kivimäkicd, Jussi Vahterabef, Tari Haahtelaa
Summary
The aim of the study is to examine the risk of sickness absence in public sector employees with allergic rhinitis or asthma or both conditions combined.
This is a prospective cohort study of 48?296 Finnish public sector employees. Data from self-reported rhinitis and asthma were obtained from survey responses given during either the 2000–2002 or 2004 periods. Follow-up data on sickness absences for the public sector employees surveyed were acquired from records kept by the employers.
During the follow-up, mean sick leave days per year for respondents were 17.6 days for rhinitis alone, 23.8 days for asthma alone and 24.2 days for both conditions combined. Respondents with neither condition were absent for a mean of 14.5 days annually. The impact of asthma and rhinitis combined on the risk of sick leave days was marginal compared to asthma alone (RR 1.1; 95% CI 1.0–1.3). In the subgroup analysis (those with current asthma or allergy medication), the risk ratio for medically certified sickness absence (>3 days) was 2.0 (95% CI 1.9–2.2) for those with asthma and rhinitis combined.
Rhinitis, asthma and both these conditions combined increased the risk of days off work.
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A pediatric asthma management program in a low-income setting resulting in reduced use of health service for acute asthma
Andrade, W. C. C.1; Camargos, P.2; Lasmar, L.2; Bousquet, J.3
Allergy, Volume 65, Number 11, November 2010 , pp. 1472-1477(6)
The effectiveness of pediatric asthma management programs in reducing health services utilization during exacerbations in developing countries is not widely studied. This study was carried out to assess the effectiveness of an asthma management program to reduce the overall health services utilization by acute asthma in children and adolescents. ?Methods:
In this historical population-based real-life cohort study, we selected 582 patients with asthma aged 4-15 living in deprived areas in the town of Itabira, Brazil, of which 470 cases were assisted by the asthma management program and 112 were controls. The end point was the first physician-diagnosed asthma exacerbation occurring after study enrollment and within 12?months after admission. All 470 cases received a written plan about exacerbation self-management, including the use of inhaled albuterol at home. Three hundred and seventeen out of 470 cases (67.4%) were also treated with beclomethasone diproprionate ?(BDP). Results:
Both groups were comparable regarding gender, age group, and place of residence. At the end of the study, only 5% of cases vs 34% of controls did seek health services because of acute asthma (P? Results have demonstrated the effectiveness of the pediatric asthma management program in reducing dependence on the health services for acute asthma. Effectiveness was also observed in subjects with no use of BDP.
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Mother’s Stress, Interference May Worsen Child’s Asthma
Kids under 7 affected by mom’s emotions, but older kids react to being overprotected, study finds

THURSDAY, Oct. 7 (HealthDay News) — A mother’s negative emotions or behavior can worsen the severity of her child’s asthma, new research suggests.

In the study, Japanese researchers followed 223 mothers for a year in order to assess how their stress levels, coping skills and parenting styles influenced asthma symptoms in their children, aged 2 to 12 years old.

Among children older than 7 years of age, a worsening of asthma was associated with mothers’ excessive interference due to being overprotective. Among children younger than 7, more severe asthma symptoms were associated with mothers’ chronic irritation and anger or a tendency to suppress expressions of emotion, the investigators found.

The study was published online Oct. 7 in the journal BioPsychoSocial Medicine.

“A mother’s stress (or well-being) may be verbally or non-verbally conveyed to her child, and affect the child’s asthmatic status via a psycho-physiological pathway, such as by immunoreactivity to allergens or a vulnerability to airway infections,” Jun Nagano, of the Kyushu University Institute of Health Science in Fukuoka, Japan, explained in a news release from the journal’s publisher.

“Our results suggest that the mothers of younger children may be advised not to worry about falling into ‘unfavorable’ parenting styles, but to pay more attention to the reduction of their own stress; and that the mothers of older children may be encouraged to increase their own well-being,” Jun concluded.
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Severe Food Allergies Turned Off in Mice
ScienceDaily (Oct. 2, 2010) — Johns Hopkins scientists have discovered a way to turn off the immune system’s allergic reaction to certain food proteins in mice, a discovery that could have implications for the millions of people who suffer severe reactions to foods, such as peanuts and milk.
The research team….discovered that one kind of immune cell in the gastrointestinal tract called lamina propria dendritic cells (LPDC) — considered the first line of defense for a body’s immune system — expresses a special receptor, SIGNR1, which appears on the cells’ surface and binds to specific sugars.
By targeting this receptor using sugar-modified protein, researchers were able to keep food proteins that would have induced a severe, even deadly, allergic reaction from causing any serious harm.
“There is no cure for food allergies, and the primary treatment is avoidance of the offending protein,” Dr. Yufeng Zhou says. “This could teach our bodies to create a new immune response and we would no longer be allergic to the protein.”
The researchers hope to confirm whether this promising process in mice can also occur in people.
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Risk stratification for hospitalization in acute asthma: the CHOP classification tree

Chu-Lin Tsai, MD, ScDb, Sunday Clark, MPH, ScDb, Carlos A. Camargo Jr, MD, DrPHa
The authors developed and externally validated a classification tree for asthma hospitalization.
Data were obtained from 2 large, multicenter studies on acute asthma, the National Emergency Department Safety Study and the Multicenter Airway Research Collaboration cohorts. The Classification and Regression Tree method identified 4 important variables (CHOP): change [C] in peak expiratory flow severity category, ever hospitalization [H] for asthma, oxygen [O] saturation on room air, and initial peak expiratory flow [P]. In a simple 3-step process, the decision rule risk-stratified patients into 7 groups, with a risk of admission ranging from 9% to 48%. The classification tree performed satisfactorily on discrimination in both the derivation and validation cohorts, with an area under the receiver operating characteristic curve of 0.72 and 0.65, respectively.
Conclusions
Use of this explicit risk stratification rule may aid decision making in the emergency care of acute asthma.
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More Genes Are Linked to Asthma Alone Than to Both Allergies and Asthma
A Large-Scale, Consortium-Based Genomewide Association Study of Asthma

Miriam F. Moffatt, D.Phil., Ivo G. Gut, Ph.D., Florence Demenais, M.D., David P. Strachan, M.D., Emmanuelle Bouzigon, M.D., Ph.D., Simon Heath, Ph.D., Erika von Mutius, M.D., Martin Farrall, F.R.C.Path., Mark Lathrop, Ph.D., and William O.C.M. Cookson, M.D., D.Phil. for the GABRIEL Consortium

N Engl J Med 2010; 363:1211-1221September 23, 2010
Background

Susceptibility to asthma is influenced by genes and environment; implicated genes may indicate pathways for therapeutic intervention. Genetic risk factors may be useful in identifying subtypes of asthma and determining whether intermediate phenotypes, such as elevation of the total serum IgE level, are causally linked to disease.

Conclusions

Asthma is genetically heterogeneous. A few common alleles are associated with disease risk at all ages. Implicated genes suggest a role for communication of epithelial damage to the adaptive immune system and activation of airway inflammation. Variants at the ORMDL3/GSDMB locus are associated only with childhood-onset disease. Elevation of total serum IgE levels has a minor role in the development of asthma. (Funded by the European Commission and others.)
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Not all who wheeze have asthma
Breathe 2010; 7: 16-22
“Asthma is characterised by respiratory symptoms such as shortness of breath and wheezing, and by exercise-induced symptoms. People with asthma frequently report symptoms during exercise; 90% of these people have exercise-induced asthma (EIA). Nevertheless, exercise-induced symptoms may mask other conditions or diseases, for instance poor physical fitness, exercise-induced laryngeal obstruction, hyperventilation and cardiomyopathy. Asthma symptoms should be documented and patients treated accordingly. With nonasthmatic exercise-induced symptoms, diseases in the laryngeal area are highly likely and patients should be examined while running. Although treatment options for laryngeal dysfunctions are limited, patients feel more in control when they know what is happening in their throat.”
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{Note: this article affirms the thesis of asthma as a study of one, explained here.}

Is Johnny wheezing? Parent–child agreement in the childhood asthma in America survey
Davis KJ, DiSantostefano R, Peden DB. Pediatr Allergy Immunology 2010. © 2010 John Wiley & Sons A/S

“We compared responses of children and parents to determine their level of agreement in a national, population-based survey regarding asthma-related health of US children. A telephone-based survey was conducted in 2004 among a national probability sample of children with current asthma in the United States. To compare responses between parent–child pairs, a subset of 284 children aged 10–15 were interviewed in addition to the parents. This survey collected data on asthma symptom prevalence, physical activity limitations and impact of exercise on asthma, and asthma management including medication use. Paired responses were compared using the kappa (?) statistic. Overall, parents of 10–15-yr-olds underestimated the burden of asthma experienced by their children, especially the effects on physical activity. More than half (58%) of children replied that exercise was a trigger for their asthma compared to only 35% of parents (? 0.23). Children were more likely than parents to mention activity limitations, specifically avoiding physical exertion (63% vs. 49%–? 0.004). Prevalence of symptoms was also underreported by parents relative to children, particularly breathing problems (41% vs. 67%–? 0.16) and cough (45% vs. 64%–? 0.14). Maintenance therapy use in the past 4 weeks was reported by 35% of children, whereas 44% of parents believed their children had used maintenance therapy (? 0.47). Relative to children’s self-report, parents underestimated avoidance tactics used by their children with asthma, including exercise and physical activity self-limitation to prevent the onset or worsening of asthma symptoms. Parents also underreported asthma symptoms of their children aged 10–15 years old and were discordant with their children regarding medication use. Increasing regular communication about asthma between child, parent, and physician is warranted to improve asthma control and overall health.”

Factors Associated with Furry Pet Ownership Among Patients with Asthma
Journal of Asthma, 09/14/2010
Downes MJ et al. – Furry pet ownership is equally or more common among asthmatics compared to those without asthma. The majority of asthmatics with furry pets allow them into the bedroom. Recognizing and addressing these problems may help decrease asthma morbidity.

A randomized trial to test the effectiveness of art therapy for children with asthma
Anya Beebe, MA, LPC, Erwin W. Gelfand, MD, Bruce Bender, PhD

A study at National Jewish Hospital in Denver concludes that art therapy may have beneficial effects on quality of life and cognitive measures for asthmatic children.
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Association of Childhood Obesity With Atopic and Nonatopic Asthma: Results From the National Health and Nutrition Examination Survey 1999-2006; Visness CM, London SJ, Daniels JL, Kaufman JS, Yeatts KB, Siega-Riz AM, Calatroni A, Zeldin DC; Journal of Asthma (Aug 2010)
Excess weight in children is associated with higher rates of asthma, especially asthma that is not accompanied by allergic disease.

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Season of birth and food allergy in children
Milo F. Vassallo, MD, PhD, Aleena Banerji, MD, Susan A. Rudders, MD, Sunday Clark, MPH, ScD, Raymond J. Mullins, MBBS, PhD, Carlos A. Camargo Jr, MD, DrPH

Conclusions
“Food allergy is more common in Boston children born in the fall and winter seasons. We propose that these findings are mediated by seasonal differences in UV-B exposure. These results add support to the hypothesis that seasonal fluctuations in sunlight and perhaps vitamin D may be involved in the pathogenesis of food allergy.”
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Survey Concludes Asthma Rates as High in Rural Areas as in Cities
A National Survey of Adult Asthma Prevalence by Urban-Rural Residence U.S. 2005
Authors: Teresa Morrison; David Callahan; Jeanne Moorman; Cathy Bailey
(Affiliation: Centers for Disease Control and Prevention, National Center for Environmental Health, Atlanta, Georgia)

Abstract
Objectives. We analyzed national data to estimate asthma prevalence among U.S. adults by urban-rural residence and to determine the relative contributions of sociodemographic and health behavior characteristics on the probability of reporting asthma. Methods. We linked the 2005 Behavioral Risk Factor Surveillance System (BRFSS) to Urban Influence Codes (UICs), categorizing respondents into four urban-rural groups: metropolitan, adjacent metropolitan, micropolitan, and remote. BRFSS collects health data from all 50 states. UICs classify respondent’s county as urban or rural based on population size and proximity to metropolitan areas. We calculated asthma prevalence estimates and generated odds ratios (ORs) for the probability of reporting asthma. Results. Overall asthma prevalence (7.9%; 95%CI = 7.73-8.08) was not statistically different (p = 0.28) by urban-rural residence. After adjusting for selected characteristics, adjacent metropolitan (OR = 0.96; 95%CI = 0.90-1.02) and remote (OR = 0.95; 95%CI = 0.85-1.05) residents were less likely—and micropolitan (OR = 1.04; 95%CI = 0.93-1.16) residents were more likely—to report asthma compared with metropolitan residents; but confidence intervals included null. Conclusions. Asthma prevalence is as high in rural as in urban areas. Certain demographic, behavioral, and health care characteristics unique to place of residence might affect asthma prevalence. Because these results substantially change our understanding of asthma prevalence in rural areas, further investigation is needed to determine geographic-related risk factors. Link

Dietary Habits and Asthma: A [Mixed] Review
Arvaniti F, Priftis KN, Panagiotakos DB; Allergy and Asthma Proceedings 31 (2), e1-10 (Mar 2010)

Many risk factors for the development of asthma and allergies have been proposed; although genetics are a major factor, the subject’s environment and lifestyle may also contribute maximally to the disease. The role of diet has recently been investigated and recognized as a potential risk factor. It has been suggested that the rise in asthma prevalence may partly reflect changes in the population susceptibility resulting from alteration in diet, especially a fall in antioxidant intake, rather than increasing environmental toxicity. Many studies have shown that the decreased consumption of fresh fruit, vegetables, fish, and the increased intake of food rich in fat, is associated with increased risk of developing asthma. More recently, larger dietary patterns beyond individual nutrients have been investigated such as the Mediterranean diet. However, the results of these studies are inconsistent and even contradictory. Despite some promising hypotheses and findings, there has been no conclusive evidence about the role of specific nutrients, food types, or dietary patterns in the development of asthma.

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Unified disease, unified management: Treating allergic rhinitis and asthma with nasally inhaled corticosteroid; Ribeiro de Andrade C, Chatkin JM, Fiterman J, Scaglia N, Camargos PA; Respiratory Medicine (Jul 2010)
Persistent allergic rhinitis (AR) and asthma constitute a common comorbidity. Combined treatment is recommended by prescribing intranasal plus oral inhaled corticosteroids. This study was carried out to assess the efficacy of an alternative regimen to treat this condition. All recruited patients suffered from persistent AR and asthma. Diagnosis and classification of AR and asthma were based on international guidelines. The experimental group received fluticasone propionate (FP), 500mug/day during six weeks, inhaled exclusively through the nose using a valved large volume spacer attached to a facemask. The comparison group also received the same dose of orally inhaled FP, during the same time period, plus intranasal aqueous fluticasone, 200mug/day. There were no statistical differences between both groups regarding AR and asthma severity, clinical scores, acoustic rhinometry, lung function, and FeNO upon admission and during the follow up period. Intragroup analysis demonstrated a significant improvement for allergic rhinitis and asthma scores as well as for FeNO from admission to the sixth week (p Link

{Note: For more about the relationship between nasal allergies and asthma, see the section on “One Airway, One Disease” in Asthma Allergies Children: a parent’s guide.}

Air Filters and Air Cleaners
Rostrum by the American Academy of Allergy, Asthma & Immunology Indoor Allergen Committee
James L. Sublett MD, b, James Seltzer MDc, Robert Burkhead ME, P. Brock Williams PhD, H. James Wedner MDf, Wanda Phipatanakul MD, MSg and American Academy of Allergy, Asthma & Immunology Indoor Allergen Committee
Home environmental intervention strategies are effective in reducing allergic respiratory disease manifestations. To date, most research has focused on allergens. Clinicians often ignore other airborne particulate matter (PM), which might play a significant role in human respiratory disease. Consequently, air filtration studies focused only on the efficacy of reducing airborne allergens might fail to recognize the health benefits of air filtration.
The study of the effectiveness of avoidance measures is limited by the fact that a single method is not enough. Multiple interventions over a long period of time (at least 1-2 years in duration) might be required to yield meaningful clinical results. Studies using single interventions (eg, well-established single interventions, such as impermeable mattress covers) in short-term trials have often proved ineffective. As a consequence, allergists might underemphasize these measures, especially in the face of the quick effect on disease symptoms offered by pharmacotherapy. Even with effective pharmacologic interventions, disease progression benefits are often lost on discontinuation. Environmental control measures might result in significant reduction of disease symptoms and progression by eliminating or reducing exposures.
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More Asthma in pregnancy

Dombrowski MP, Schatz M; Clinical Obstetrics and Gynecology 53 (2), 301-10 (Jun 2010)
Asthma is an increasingly common problem during pregnancy. Mild and moderate asthma can be associated with excellent maternal and perinatal pregnancy outcomes, especially if patients are managed according to contemporary recommendations of National Asthma Education and Prevention Program. Severe and poorly controlled asthma may be associated with increased prematurity, need for cesarean delivery, preeclampsia, and growth restriction. Severe asthma exacerbations can result in maternal morbidity and mortality, and can have commensurate adverse pregnancy outcomes. The management of asthma during pregnancy should be based upon objective assessment, trigger avoidance, patient education, and step therapy. Asthma medications should be continued during pregnancy and while breast-feeding.
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Small Fraction of Children with Food Allergies Referred to Allergists by ER Doctors After Anaphylaxis

Susan A. Rudders, MD, Aleena Banerji, MD, Blanka Corel, MD, Sunday Clark, MPH, ScD, Carlos A. Camargo, Jr, MD, DrPH

An article in the March 2010 issue of Pediatrics found that among children who were admitted to Boston emergency rooms for food-related anaphylaxis, “43% were prescribed self-injectable epinephrine, and only 22% were referred to an allergist.”
The study doesn’t say how many of the 78% of patients not referred to an allergist returned to the emergency room at a later date. (more…)

Asthma in Pregnancy

Michael Schatz, MD; Mitchell P. Dombrowski, MD
The New England Journal of Medicine (April 30, 2009)

Summary: Asthma is probably the most common potentially serious medical problem that occurs during pregnancy. Approximately 8% of pregnant women reported current asthma in recent national surveys. Studies adjusted for potential confounders show that women with asthma have been reported to have higher risks of several complications of pregnancy, including preeclampsia, preterm birth infants with low birth weight or intrauterine growth restriction, infants with congenital malformations, and perinatal death than women without a history of asthma. Many women fear use of asthma control drugs during pregnancy because they fear the effects on the fetus, but treatment may reduce serious risks to the mother resulting from uncontrolled asthma, including death, and produce better outcomes.

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Asthma Care Quality for Children With Minority-Serving Providers
Alison A. Galbraith, MD, MPH; Lauren A. Smith, MD, MPH; Barbara Bokhour, PhD; Irina L. Miroshnik, MS; Gregory S. Sawicki, MD, MPH; James H. Glauber, MD, MPH; Katherine H. Hohman, MPH; Charlene Gay, BA; Tracy A. Lieu, MD, MPH
Arch Pediatr Adolesc Med. 2010;164(1):38-45.

A Medicaid-predominant health plan and multispecialty provider group in Massachusetts studied 563 children with persistent asthma, identified by claims and encounter data.
Children with persistent asthma were found to be less likely to receive inhaled steroids if they receive care in community health centers or hospital clinics.
Practice setting mediated initially observed disparities in inhaled steroid use by
Latino children and those with minority-serving providers. No differences by race/ethnicity or minority-serving provider were observed for influenza vaccinations
or asthma action plans. (more…)

Status of Childhood Asthma in the United States, 1980–2007
Lara J. Akinbami, MD, Jeanne E. Moorman, MS, Paul L. Garbe, DVM, MPH, Edward J. Sondik, PhD

Centers for Disease Control and Prevention data were used to describe 1980–2007 trends among children 0 to 17 years of age and recent patterns according to gender, race, and age. Asthma period prevalence increased by 4.6% per year from 1980 to 1996. New measures introduced in 1997 show a plateau at historically high levels; 9.1% of US children (6.7 million) currently had asthma in 2007. Ambulatory care visit rates fluctuated during the 1990s, whereas emergency department visits and hospitalization rates decreased slightly. Asthma-related death rates increased through the middle 1990s but decreased after 1999. Recent data showed higher prevalence among older children (11–17 years), but the highest rates of asthma-related health care use were among the youngest children (0–4 years). After controlling for racial differences in prevalence, disparities in adverse outcomes remained; among children with asthma, non-Hispanic black children had greater risks for emergency department visits and death, compared with non-Hispanic white children. For hospitalizations, for which Hispanic ethnicity data were not available, black children had greater risk than white children. However, nonemergency ambulatory care use was lower for non-Hispanic black children. Although the large increases in childhood asthma prevalence have abated, the burden remains large. Potentially avoidable adverse outcomes and racial disparities continue to present challenges. These findings suggest the need for sustained asthma prevention and control efforts for children.” (more…)