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Enroll in #asthma study for adults/children who lost insurance coverage due to #COVID19 #pandemic

Researchers at Harvard Medical School and the Harvard Pilgrim Health Care Institute are conducting a study for adults with asthma or parents of children with asthma who lost have insurance coverage during the COVID pandemic.

This study will be looking at the effect of an insurance navigation assistance program to help participants who fit these criteria. The navigation assistance will include online information and the opportunity to get insurance information from trained navigators, as well as the opportunity to get help by telephone with a navigator from the Asthma and Allergy Foundation of America (AAFA). AAFA is a national non-profit organization that aims to control and prevent asthma and allergic conditions through patient education, public awareness, and support for research.

If you are qualified and chosen to participate in this study, you will receive all study-related procedures at no cost! You will also be reimbursed for your time participating in this study.

Participation in this study is limited to one person per household.

To learn more and find out if you qualify to participate, visit: https://www.aafa.org/afford-study

#Asthma during #pregnancy poorly controlled

Today’s blog post comes from a study conducted by Dr. Jacqueline M. Cohen et al. and published in The Journal of Allergy and Clinical Immunology: In Practice. The study reports that poorly controlled asthma during pregnancy remains common in the United States.

Why did the authors conduct the study?

· Asthma is currently estimated to complicate between 3%-10% of pregnancies.

· Pregnant women with uncontrolled asthma may have an elevated risk for adverse maternal and neonatal outcomes.

· 1/3 of women may discontinue asthma controller medications early in pregnancy to avoid fetal toxicity or because of uncertainty about the appropriate asthma medications.

· Previous studies suggest that the increase in asthma symptoms described in a proportion of pregnant women may be attributable to inadequate medication rather than worsening of asthma due to the pregnancy itself.

How did the authors conduct their study?

· The authors identified pregnancies within 2 large US health care claims databases, MarketScan which includes privately insured individuals and Medicaid Analytic eXtract which includes publicly insured individuals) to describe the prevalence of asthma, level of asthma severity, fills of asthma medications, and risk of asthma exacerbations during pregnancy.

· The study population included pregnancies in women aged 12 – 55 years who had asthma and filled an asthma-specific prescription medication.

· Poor asthma control was defined as

o 5 or more fills of albuterol or

o 1 or more asthma exacerbations during pregnancy

What did the authors find?

· The number of pregnancies complicated by asthma was 20,104 in MarketScan and 120,745 in Medicaid.

· There was a larger proportion of women with poorly controlled asthma in Medicaid (28%) than in MarketScan (17%).

· 38% (MarketScan) and 43% (Medicaid) of women whose asthma symptoms were poorly controlled did not fill a controller medication during pregnancy.

· The proportion of women with 1 or more exacerbations during pregnancy was similar for women with mild asthma at baseline (14% in MarketScan and 21% in Medicaid) compared with those with severe asthma at baseline.

· Asthma was approximately twice as common in publicly vs. privately insured pregnant women.

· During pregnancy, the frequency of asthma-related hospitalizations was 1.6% in MarketScan and 5.1% in MAX.

· High prevalence of poorly controlled asthma among pregnant women in the United States, particularly in the Medicaid population.

What does this mean?

· Factors associated with low socioeconomic status, smoking, obesity and comorbidities may contribute to poor asthma control during pregnancy.

· Use of long-acting controllers remains low, even for symptomatic patients, potentially out of fear regarding fetal toxicity.

· Appropriate therapeutic management during pregnancy could improve the health of both mothers and children, there is a need to provide additional evidence on the risk and benefits of asthma medications in pregnancy.

A pediatric pulmonologist’s view on #e-cigarettes #e-cigs #vaping

Today’s post is from Robyn Cohen, MD, Director of the Pediatric Pulmonary & Allergy Clinic at Boston University School of Medicine. She writes....

As a Pediatric pulmonologist and mother of teen and tween, I feel compelled to post the attached webinar about the fraud that Juul and other e-cig manufactures are perpetrating on the public, specifically kids who are particularly vulnerable to the marketing efforts by a billion dollar industry to use the cool mango flavored flash drive pods to get a good buzz. It is a *mindblowing* 45 minutes by an inhalational toxicologist. For those of you without that kind of time, here are the highlights:

1) Juul is a delivery device for a form of nicotine specifically engineered to be less irritating to the throat, and more rapidly and completely absorbed into the bloodstream in order to optimize its addictive properties. (Developed by 2 Stanford MBA students.)

2) While vanilla, banana, mango, and other flavors are safe for ORAL ingestion, they are chemical aldehydes that are NOT safe for inhalation. Among other things, one mechanism of their toxicity is completely destroying the function of the immune cells of the lungs.

3) Therefore I repeat, even the non-nicotine flavored vape products are NOT safe. (This includes MONQ, the personal essential oil vape pens that heats the oils to 220 degrees for inhalation. With names like “Sexy” and “Zen.”)

4) Juul pods contain 4x the amount of nicotine as a pack of cigarettes.

5) Kids who vape are 3-4x more likely to become regular cigarette smokers than kids who don’t vape, and much more likely to graduate to putting other stuff into their vaping device.

It’s a fraud that our kids are buying into hook, line, and sinker. What’s even worse - so is the FDA.

#Asthma and #school performance in urban children

Today’s blog post is about a study conducted by Dr. Noinis Mitchell et al. and focuses on asthma and academic performance in urban children. The study was conducted in Providence, Rhode Island.

Why did the authors conduct the study?

Urban minority children are at increased risk for asthma morbidity.

Children with asthma are more prone to school absences than their healthy peers; urban minority children with asthma are at even greater risk.

Factors that place individuals in urban living at risk for asthma:

Exposure to urban stressors and violence

Neighborhood stress

Environmental irritants and allergens

Poorer medication adherence

Cultural factors related to racial/ethnic background

Frequency of absences is an important indicator of asthma morbidity in children and has been used as a proxy for academic performance in studies including children with asthma.

The extent to which asthma affects urban children’s academic performance across multiple academic indicators is not well documented.

How did the authors conduct their study?

Data were collected within a larger 5-year study, Project Nocturnal Asthma and Performance in School, that assessed the co-occurrence of asthma, allergic rhinitis, sleep quality, and academic functioning in urban children and healthy controls across an academic year.

Participants were recruited from the 4 largest urban school districts in an urban Northeast US city and form hospital based ambulatory pediatric clinics.

Eligibility criteria:

Age between 7-9 years old.

Legal guardian was willing to participate and self-identified as Latino (Dominican/Puerto Rican), black/African American, or non-Latino white.

Attends an urban public school in 1 of the 4 targeted school districts that are identified as being high-risk for asthma prevalence and asthma-related health care utilization.

Physician-diagnosed asthma or caregiver-reported asthma symptoms in the previous 12 months.

At screening:

Each child was initially evaluated for persistent asthma either by caregiver report of a current prescription for asthma controller medication

OR report of recurrent daytime or nighttime symptoms, activity limitation, rescue medication use

OR 2 or more oral steroid burst in the prior 12 months

Assessment of academic indicators occurred concurrently with asthma monitoring; each child’s teacher was asked to complete a 2-week short term academic performance assessment that dovetailed with the last 2 weeks of the monitoring period.

Caregivers reported how often missed doses of daily controller medication on a scale from 1 (misses doses all of the time) to 5 (never misses doses).

At the end of the monitoring period, families completed the Childhood Asthma Control Test (ACT).

Each participant’s primary classroom teacher reported on the participants academic performance during 2 weeks within the monitoring period in which the child’s asthma was assessed.

What did the authors find?

Asthma severity was negatively associated with quality of school work.

Among children with asthma, better lung function was associated with teacher reports of better quality of school work and less careless work.

Better asthma control was significantly associated with higher quality of work and fewer absences and borderline associated more work completed and higher math scores.

Significant associations were found between asthma and academic indicators stratified by ethnicity.

Among Latinos better lung function was associated with less careless school work as well as higher math and reading scores.

Among black children, more daily reported symptoms were associated with more school absences.

Among non-Latino white children, there were borderline associations between better lung function and better quality of work.

More daily reported symptoms were significantly associated with worse quality of work, worse math scores, and more school absences.

What does this mean?

Poor asthma control can affect children’s daily functioning. Children’s optimal school performance, a key factor in their future learning and academic trajectory is at stake.

Asthma management education for students, caregivers, and school staff is needed to provide clear asthma response plans for students experiencing symptoms at school.

Increased communication between caregivers, teachers, and school nurses about the asthma care of children can ensure that students’ asthma response plan in school is clear and that they have available rescue medications at school.

Asthma control is modifiable urban school are faced with barriers that may limit optimal asthma management at school; interventions designed to increase parent-provider-school partnerships should be encouraged to address these barriers.

Health risk behaviors, violence exposure, and current asthma among adolescents in the United States

Today’s guest post is based on the study by Drs. Yueh-Ying Han, Erick Forno, and Juan Celedón about health risk behaviors, violence exposure, and current asthma among teens.

Why did the we conduct the study?

· Total estimated annual costs related to asthma reach $81.9 billion.

· Asthma leads to almost 14 million missed school days every year in children 5-17 years old.

· Adolescents may engage in risk behaviors that have been associated with worse asthma outcomes, including poor symptom control and lower health related quality of life.

· Current evidence also suggests that psychosocial stressors and depression play a role in asthma pathogenesis.

· Our aim was to assess the relationship between health risk behaviors (marijuana use, dietary patterns, etc.) or psychosocial stressors (exposure to violence and victimization) and asthma among high school adolescents in U.S.

· We also examined whether any estimated effects of psychosocial stressors on asthma are at least partly explained (or mediated) by depressive symptoms or suicidal behavior.

How did we conduct the study?

· We analyzed data from study subjects that participated in the Youth Risk Behavior Surveillance System (YRBSS) survey.

o The YRBSS was established by the US Centers for Disease Control and Prevention (CDC) to monitor the prevalence of youth behaviors that most influence health.

o For this study, we combined data from the 2009 and 2011 YRBSS.

o YRBSS questionnaires are self-administered and used to collect information on demographic characteristics, health risk behaviors, psychosocial stressors, and asthma.

· Current asthma cases were defined by a positive answer to both of the following questions:

o “Has a doctor or nurse ever told you that you have asthma?”

o “Do you still have asthma?”

o Negative answers were selected as a control subject

· Health risk behaviors we considered for our analysis included:

Frequency of physical activity in the past week

Average hours of sleep

Body mass index (BMI)

Fruit or vegetable consumption in the past week

Regular soda or pop consumption in the past week

Current smoking

Marijuana use in the past month

Use of illegal drugs (cocaine, heroin, methamphetamines, ecstasy)

· Psychosocial stressors were measured through:

Six measures of violent behavior (whether the adolescent has ever carried any weapon, carried a gun, carried any weapon to school, been in a physical fight, been injured in a physical fight, or been in a physical fight at school).

Five measures of victimization (whether the adolescent has ever feared to attend school, been threatened or injured by a weapon at school, been physically abused by a dating partner, been coerced into sex, or been bullied at school).

Three measures of suicidal behavior (whether the adolescent has ever considered suicide, planned suicide, or attempted suicide).

What did we find?

· We found that high-schoolers with current asthma (compared to those without asthma) are more likely to be female, overweight or obese, and current smokers; they reported fewer hours of sleep; eat fruit or vegetables more frequently; drink soda/pop more frequently and report use of marijuana more frequently.

· We also found that exposure to any violent behavior or any victimization were each associated with current asthma after adjusting for multiple other characteristics. Moreover, these associations were partly explained by depressive symptoms or suicide behaviors.

What does this mean?

· Asthma remains a significant public health burden among adolescents in the United States.

· Our study identifies potentially modifiable risk factors for asthma morbidity in adolescents including poor dietary and sleep habits, obesity, and violence-related depressive symptoms.

· There is emerging evidence supports that psychosocial stressors at individual, family and community levels have negative impact on asthma.

· It is important to understand that promoting a healthy weight and diet, encouraging enough sleep, and early detection and treatment of violence and depressive symptoms could help reduce the asthma burden in adolescents.

Does #asthma lead to #depression or does depression lead to asthma?

Today’s blog post is about an article by Dr. Choi et al that was published recently in The Journal of Allergy and Clinical Immunology: In Practice. The study examines the association between the diagnoses of asthma and depression.

Why did the authors conduct the study?

· The World Health Organization World Health Survey shows 18% of adults with asthma have comorbid depressive disorders.

· Depression and anxiety are more common in adults with asthma than in the general population.

· Previous studies involving adults found asthma could be a risk factor for incident adult-onset asthma or worse outcomes for asthma.

How did the authors conduct their study?

· Using a nationwide population in Korea, the authors investigated whether:

Asthma could predict the development of depression Depression is associated with subsequent asthma development in an adult population.

· Participants were selected if they were diagnosed with asthma by a physician more than 2 times and those treated with asthma medications. Depression was defined using billing codes.

· Study 1 looks at individuals with asthma and looks to see if they have depression.

Participants with asthma were matched with participants who were never diagnosed with asthma.

Matching was performed on the basis of age group, sex, income group, region of residence, and medical history.

The matching resulted in 112,524 participants with asthma and 112,524 control participants.

· Study 2 looks at individuals with depression and looks to see if they have asthma.

Participants with depression were matched 1:4 with participants who were never diagnosed with depression.

Matching resulted in the inclusion of 52,535 participants with depression and 210,140 control participants.

What did the authors find?

· Of the 225,048 participants, 6.5% were diagnosed with depressive disorders, including 7.4% who had asthma and 5.5% who did not have asthma (suggesting more people with asthma have depressive disorders).

· 11.3% of participants in the depression cohort were newly diagnosed with asthma; 9.2% of participants who did not have depression were diagnosed with asthma during the same period.

· People with asthma were 1.35 times more likely to have a depressive disorder.

· People with depressive disorders were 1.25 times more likely to have asthma suggesting that there might be a bidirectional association between the two diseases.

What does this mean?

· This study demonstrated that depression is associated with subsequent asthma development AND asthma is associated with subsequent development of depression.

· Depressive symptoms and uncontrolled asthma are both modifiable factors that could be used to control each disease.

#Racial/Ethnic Variation in Emergency Department Care for #Children with #Asthma

Today’s blog post features a recent study by Heather Zook, MA et al that was published in Pediatric Emergency Care. Zook et al examined whether there was variation in treatment of asthma for children in the emergency department.

Why did the authors conduct the study?

· Asthma is among the top 5 diagnoses for which children present to the emergency department (ED).

· African Americans have the highest asthma prevalence along with the highest rate of asthma-related ED visits.

· No studies have focused on treatment in the ED.

· There is currently a wide variation in asthma treatment across EDs.

How did the authors conduct their study?

· The authors conducted a cross-sectional analysis of pediatric patients who presented to one of six EDs in Upper Midwest.

· They included patients with a primary diagnosis of asthma and who received albuterol in the ED.

· The authors used 30-day ED revisit rates as a marker for poor disease control (defined a patient who presented with asthma and then returned to the ED within 30 days of the index visit).

What did the authors find?

· American Indians, African Americans, Asians, Hispanics, and other minorities were more likely to receive rescue medications (steroids) in the ED than whites.

· White children were more likely to have radiology (such as x-rays) ordered than children from all other racial/ethnic groups.

· Asians and white patients had lower proportion of revisits to the ED compared with African American and Hispanics.

· Children with public insurance had significantly higher odds of revisits within 30 days compared with those of private insurance.

What does this mean?

· Minority children were more likely to receive oral steroids in the ED than white children, yet white children were more likely to receive xrays than minority children. The reason for this discrepancy is unclear to me. The authors state the reasons are likely multifactorial, including varying levels of disease severity, health literacy, and access to care.

· Higher rates of testing have been seen in other studies in whites compared with nonwhites in the ED for conditions such as asthma, appendicitis, and chest pain.

· The authors also state that the higher rates of administration of rescue medications for African American, Hispanic, and other children in the ED may relate to racial/ethnic differences in parental perceptions of asthma. And for this point, the authors cite a study I led over ten years ago on racial/ethnic variation in parent perceptions of asthma. Click [here] for my article.

#Mindfulness and #Asthma

Today’s blog post is about an article by Dr. Shi et al that was published recently in the Journal of Asthma. The study examines the association between mindfulness and asthma symptoms.

First, what is mindfulness? Mindfulness is the basic human ability to be full present, aware of where we are and what we’re doing, and not overly reactive or overwhelmed by what is going on around us. Mindfulness can be cultivated through proven techniques, mainly through seated, walking, standing, and moving meditation; Mindfulness can be short pauses we insert into everyday life; fusing together meditation skills with other skills (i.e. yoga, or physical activity). For more information on mindfulness visit https://www.mindful.org/what-is-mindfulness/

Why did the authors conduct the study?

· Previous studies have shown that mindfulness helps a variety of health outcomes among different populations.

· There is a known link between stress and asthma; with this link the authors find it plausible that mindfulness might play a role in affecting asthma related outcomes.

· Past studies have shown that through mindfulness has had significant movement in asthma related quality of life and significant improvement in perceived stress.

· Previous studies had relatively small sample size which limits the generalizability of findings; current studies focused on effects of mindfulness training instead of studying mindfulness as an inherent trait.

How did the authors conduct their study?

· The study sampled 1516 college freshman in the Shanghai University of Finance and Economics.

· Mindfulness was measured using a widely used scale that consisted of 15 questions: Mindful Attention Awareness Scale (MAAS).

· Study participants completed a self-reported survey of questions that asked on participants diagnosis of asthma or having a history of dry cough or history of wheezing or all the above.

What did the authors find?

· Students with higher level mindfulness were less likely to have asthma diagnosis and persistent dry cough.

· Mindfulness training could improve asthma-related quality of life and level of stress and anxiety among individuals with asthma.

· Significant associations exist between mindfulness and asthma; first year students with a higher level of mindfulness were less likely to have asthma diagnosis and symptoms.

What does this mean?

· Mindfulness may have a direct relationship when stress and asthma.

· Mindfulness training might be promising in improving asthma control among college students.

· The authors hypothesize that chronic stress in life could affect both asthma and trait mindfulness.

#Parabens could affect #asthma outcomes

Today’s post focuses on an article by Lesliam Quiros-Alcala, PhD, MS and co-investigators about a study recently published in the Journal of Allergy and Clinical Immunology. Parabens are preservatives that are used in make-up, lotions, shampoos, food products, and more to prevent growth of bacteria and fungi. Recently there has been concern that parabens could be bad for health, including asthma.

Why did the authors conduct the study?

· In recent years, there has been concern about the potential effects of parabens on pediatric respiratory health.

· Paraben exposure is widespread (where some selected parabens detected in more than 90% of the general population).

· It’s possible that antimicrobial properties of parabens could promote an allergic picture by altering the microbiome of the gut, respiratory tract or in some cases both.

· Few studies examine the role of paraben exposure on the risk of pediatric respiratory and allergic disease.

· No studies have examine whether exposure to parabens are associated with worse-asthma related outcomes.

How did the authors conduct their study?

· The authors looked at the association between exposure to parabens and whether children had a current asthma diagnosis.

· Participants were ages 6 years - 19 years in the NHANES (National Health and Nutrition Examination Survey). The study included 4,023 participants and 450 reported having a current asthma diagnosis.

· Participant information was collected through a household interview about whether the child had asthma.

· Paraben exposure measurement was done through urinary biomarker concentration of different parabens in spot urine samples.

· Parabens tested included:

o Butyl paraben [BP] o Ethyl paraben [EP] o Methyl paraben [MP] o Propyl paraben [PP]

What did the authors find?

· With the four Parabens that were being studies, BP and EP were not widely detected but MP and PP were detected in more than 95% of children.

· MP and PP were significantly higher among children reporting a current asthma diagnosis compared with children w/ no current asthma diagnosis.

· Boys were more likely to have ED visits for asthma than girls in general, and exposure to parabens in boys further increased the likelihood of ED visits.

· MP and PP appear contribute to asthma symptoms among but are not associated with development of asthma.

What does this mean?

· Parabens are commonly detected on children.

· Parabens might be associated with increased asthma exacerbations.

#Asthma is unique at every age

The current issue of the Journal of Allergy and Clinical Immunology In practice is entitled Asthma Across the Ages. A whole issue devoted to ASTHMA! I had a lot of fun coordinating this issue with Paul Greenberger.

The goal of this issue is to provide an across the spectrum of life perspective on asthma in order to hopefully contribute new insights on asthma management to improve care for patients. Our editorial that accompanied the issue, entitled Asthma: Overdiagnosed, Underdiagnosed, and Ineffectively Treated, was motivated by recent data from the Centers for Disease Control (CDC) that showed that minorities, particularly black non-Hispanics and Puerto Ricans still suffer a disproportionate share of the burden of asthma. Black non-Hispanics have a 3-fold higher asthma death rate than white non-Hispanics or Hispanics. And close to 50% of patients with current asthma had experienced at least one an asthma flare in the previous 12 months.

We still have so much work to do.

What complicates asthma treatment is we still do not have a definitive way of diagnosing asthma. So, sometimes we overdiagnose. For example, obese patients who are more likely to report shortness of breath may be overdiagnosed.

Sometimes we underdiagnose. Older adults are more likely to be underdiagnosed because they may be diagnosed with COPD.

And this can lead to undertreatment, which leads to asthma flares.

We invited authors with expertise in asthma across the age spectrum to contribute articles. Here are a few highlights. This issue is packed with articles about asthma. Guess who the titles were inspired by?

Prenatal:

In a review entitled, “As You Eat It: Effects of Prenatal Nutrition on Asthma,” Lee-Sarwar and Litonjua et al provided a summary of the literature on the effect of diet during pregnancy on risk of childhood asthma. Vitamin D supplementation may have a protective effect on the development of childhood asthma.

School-aged children:

Naja et al reviewed asthma in school-aged children, providing an overview of racial/ethnic and socioeconomic disparities to environmental exposures to novel treatments. Their review is “Taming Asthma in School-Aged Children: A comprehensive Review.”

Adolescents:

Being a teen these days is hard enough. Having asthma as a teen is even harder. Burg et al review real-world challenges for tens with persistent asthma in “The Tempest: Difficult to Control Asthma in Adolescence.” How do we teach teens self-efficacy?

Adults over age 65 years:

Older individuals with asthma have unique challenges with co-existing illnesses such as heart conditions, sleep apnea, obesity or COPD. Effectiveness of treatments may be different for older individuals and newer medicines. Baptist and Busse review these issues in Asthma Over the Age of 65: All’s Well That Ends Well.

So, no matter what age group you care about, this is a must not miss issue for asthma!

A new tool to help support better asthma management

Today’s blog post is from Barbara P. Yawn MD MSc, Director of Research, Olmstead Medical Center, University of Minnesota. She writes about a recently published study on a tool she developed to help improve rates of asthma control.

Asthma burden is more than just going to the emergency room or hospital for severe asthma attacks. Over half of people with asthma have symptoms more than 2 days or nights each week—symptoms like wheezing, coughing and shortness of breath or that keep them from doing the activities they would like to do. We have given this a label as “out of control” asthma and score cards like the Asthma Control Test (ACT) give scores to tell clinicians or families that their asthma is out of control.

Too often, having out of control asthma results in simply giving more asthma medication. But often that is not the best answer. A newer tool called the Asthma APGAR helps measure the burden but goes on to assess the most common reasons for asthma being “out of control”. Those reasons include:

· Allergic triggers or irritants like dust mites, pets, mold, cockroaches or seasonal pollens from trees, flowers or grasses or irritants like tobacco smoke

· Inability or concerns about taking asthma medications daily—once or twice a day

· Incorrect inhaler technique so that the medicines from the inhalers do not get into the lungs.

The Asthma APGAR asks questions about triggers, how you talk your medications and why you do or do not take them and whether or not you think the medications help your asthma.

The tool also includes a list of questions for you or your doctor, nurse or physician assistant to discuss that can help bring out more details about your activities and how they may have changed due to your asthma, more about triggers that seem to make your asthma worse and reasons why you find it difficult or uncomfortable to take asthma medications.

The control score (first 3 questions) and the other responses are linked to a care flow chart or algorithm that can guide next steps in your care. It is color coded---red is for an acute asthma attack that requires immediately attention usually with additional medication or even oxygen. Yellow is for people with out of control scores---2 or higher on the Asthma APBGAR. And green is for times when the asthma seems to be in control and not bothering your usual activities.

For the yellow times, the algorithm reminds you and your clinician to not just prescribe more medicine but to explore reasons for the problems including making sure they have explained and watched you use each of your inhalers. Different inhalers require slightly different techniques (see box below).

By circling any of the triggers that you think may make your or your child’s asthma worse, you can help guide an allergy assessment. Over 90% of children and about 70% of adults have some allergy sensitivities. Without identifying and either avoiding those triggers or treating those problems, it may be very hard to control asthma symptoms. Allergic sensitivities can be assessed by a blood test that includes 10 to 12 of the most common allergies in your geographic area, by allergy skin tests or by exposing you to the triggers and watching for symptoms—like noticing that your asthma gets worse every time to visit your friend or neighbor with a cat. Dust mites are very common problems that don’t mean you are a poor housekeeper---they are in many households except those above 3,000 feet in altitude where dust mites don’t like to live. Mold and even cockroaches can be common in warm humid climates and require care but often can be removed. Other allergies may be seasonal and respond to increased asthma and allergy medications. Some allergies require immunotherapy---either as asthma allergy “shots” usually given by an allergist or for some allergens, sub-lingual drops you can use at home after a few doses given in a clinic.

Reasons for not taking medications as prescribed—labeled adherence—are many but often include:

· Not understanding why, when or how the medications are to be used. Remember that most people with asthma have 2 kinds of medicine---one for quick relief when symptoms get worse and one or more they need to take daily called maintenance medicines like inhaled corticosteroids.

· Having a very busy life that makes it difficult to remember things regularly. Putting the medicines in an obvious but safe place where you will notice them---like near your bed if you use medicine morning and evening can help. Using a calendar on the refrigerator to check them off daily or an app on your smart phone can also work.

· Not being able to pay for the medicine or pay the co-pays can make it difficult to have what you need. If this is a problem, it is better to ask your doctor or nurse or people in the clinic about any programs that could help and to make sure you are only taking medicines that you need. Simply taking less medicine on your own often does not work.

Ok, that is a lot of information available from one tool. Does it work? YES. In a study of over 1200 people with asthma (ages 5 to 45 years of age) who were cared for in primary care offices scattered around the country, using the Asthma APGAR system led to improved rates of asthma control and to a 50% decrease in asthma visits to the emergency room or hospital in the group using the Asthma APGAR compared to patients in clinics not using the Asthma APGAR.

The Asthma APGAR can be put on your refrigerator to allow you to follow how things are going. If you mark several of the triggers, ask your doctor, nurse or physician’s assistant to do more evaluation to see what can be done if you have allergies. Sharing any problems, concerns or fears about taking the medications and making sure you know which is for what purpose as well as asking them to watch you use your inhalers lets you guide your care.

For children, the Asthma APGAR can be shared with the school nurse or even the day care center to help them learn more about asthma and let you know what is happening while your child is in day care or at school.

The Asthma APGAR system works to support better outcomes for patients. It is one of the only control scores that has been tested to show how it affects asthma care and it is the only one that helps busy primary care clinicians next steps.

Does #obesity cause #asthma, or does asthma cause obesity?

How often I’ve been told by a parent that their child’s obesity was because he or she couldn’t exercise because of asthma. But I’ve never been told that a child’s obesity caused the child’s asthma. Or that a child’s obesity made her asthma worse. We know that asthma and obesity are related. But which comes first? It turns out it could be both. A recent article in the Journal of Allergy and Clinical Immunology by Ubong Peters PhD et al reviews this topic.

So, it turns out:

Obese subjects are more likely to have asthma.

Obese asthmatic individuals are more likely to have symptoms, more frequent and severe flares, and poorer response to asthma medications, and decreased quality of life.

Both asthma and obesity are common in children and adults. In the U.S., 9% of children have asthma and 17% are obese (with another 15% being overweight). In adults, 7% of lean adults have asthma while 11% of obese adults have asthma.

In children, asthma can lead to obesity.

But most studies suggest obesity changes asthma by increasing asthma severity, leading to poorer control and lower quality of life.

In adults, obese adults have a much higher risk of being hospitalized than lean adults with asthma.

In children and adults, obesity has a significant effect on lung function.

Diet may play a role. Obesity is associated with low circulating vitamin D levels, and multiple studies have suggested that vitamin D deficiency may be linked to asthma exacerbations. Furthermore, diets that are high in saturated fatty acids that promote obesity also are associated with asthma. On the flip side, breastfeeding is associated with lower risks of both asthma and obesity. Beverages containing high sugar levels are risk factors for asthma and obesity.

Diet also affects the gut microbiome (microorganisms in the gut), and the Western dietary pattern is known to alter the gut microbiome to promote obesity. This might also affect development of allergic airway disease.

Weight loss interventions appear to improve asthma outcomes

What does all this mean?

Obesity is an important risk factor for asthma and symptoms related to asthma in both children and adults.

Even though there are commonalities between adults and children, there are different characteristics between age groups.

Potential underlying mechanisms for asthma and obesity include:

Shared genetic component

Dietary and nutritional factors

Alterations in the gut microbiome

Systemic inflammation

Metabolic abnormalities

Changes in lung anatomy and function

So, asthma and obesity are definitely related, but much is still unknown, including:

How to classify obese and non-obese asthma

Whether new treatments might be better for individuals with obesity and asthma

Who uses #peakflow meters for #asthma?

I’ve been thinking through the role of the new peakflow and spirometry apps, that look super cool, on clinical practice. Here’s documentation of the Twitter conversation related to my question.

Who invented the stethoscope?

It’s one of the most defining items for doctors. 1 year old patients will imitate how to use mine by putting it behind their necks. 5 year old patients will ask to try to take a listen to their hearts beat. It’s the one item I’m lost without in clinic. It’s the basis of diagnosing asthma.

The stethoscope.

So, who invented it? A recent essay by Professor Goran Wennergren tells us that Rene Laennec invented the stethoscope over 200 years ago.

The stethoscope was invented in 1816 while Dr. Laennec was a physician in Paris. The Laennec stethoscope was a wooden cylinder, but in the beginning, Laennec used tightly rolled sheets of paper as his stethoscope.

He tried multiple materials for the stethoscope before deciding that wood was the best. The name “stethoscope” comes from the Greek words stethos for chest and skopein for look.

Before the invention of the stethoscope, physicians placed their ears on the patients’ chests.

The modern stethoscopes that we are familiar with now, with two ear pieces, were invented in 1851 by Arthur Leared, an Irish physician.

A photo of one of the first stethoscopes.

And here’s a picture of Rene Leannec.

No need to increase inhaled steroids at first sign of #asthma symptoms

Earlier this month, the New England Journal of Medicine published a study called “Quintupling Inhaled Glucocorticoids to Prevent Childhood Asthma Exacerbations.” Now that many have had a chance to read and think about this, I’m hoping this post opens up a dialogue on how this study is influencing practice.

Details are below. Briefly, the study found that in children with persistent asthma who were on daily inhaled corticosteroids, quintupling the dose of inhaled steroids for 7 days at early signs of loss of asthma control did not improve asthma outcomes.

Some of the questions I’ve received are:

· Does this mean we should go right to combination inhaled corticosteroids/long acting beta agonists (such as Advair, Symbicort), rather than increasing the dose of inhaled steroids to control asthma?

· The study found that children who received the quintupled dose of inhaled steroids had decreased height. Would it be better or worse to give oral steroids?

Many of the best asthma providers recommend that patients increase the dose of inhaled steroids at the first sign of asthma symptoms. Still, many providers don’t believe increasing the dose of inhaled steroids makes a difference.

First, some more details about the study:

Why did the authors conduct the study?

Children with persistent asthma are often prescribed inhaled corticosteroids as a preventive medicine, to prevent symptoms. Many clinicians increase the doses of inhaled steroids at the first signs of symptoms, at early signs of loss of control of asthma.

The recommendation to increase the dose of inhaled corticosteroids is recommended in GINA (Global Initiative for Asthma) guidelines, but not in U.S. National guidelines. According to the GINA guidelines 2018, For patients taking conventional maintenance inhaled steroid-containing treatment, this should generally be increased when there is a clinically important change from the patient’s usual level of asthma control…” The reference for this recommendation is a study by Gibson and Powell in 2004 on written action plans for asthma.

Gibson and Powell conducted a review of 26 randomized clinical trials that compared action plans to usual care. The focus of their review was on whether written action plans helped improve asthma outcomes. Thirteen of the trials increased both inhaled steroids and oral steroids. Four trials recommended use of oral steroids alone but these studies had insufficient data. None of the studies only increased the inhaled steroid dose. So, all of the studies analyzed recommended inhaled steroids and oral steroids at the start of symptoms and they found an improvement in asthma when inhaled steroids and oral steroids were recommended.

But was it the increase in inhaled steroids or addition of oral steroids that improved asthma outcomes? This part was unclear, making this recommendation uncertain.

Another review in 2016 by Kew et al looked at 8 randomized trials (3 pediatric and 5 adult) and found that current evidence does not support increasing the dose of ICS at the start of symptoms. Given the uncertainty of these findings, a definitive trial is needed.

How did the authors conduct their study?

· They studied 254 children, ages 5 to 11 years who had mild to moderate persistent asthma

· All children had at least one asthma flare treated with oral steroids in the prior year

· Children were treated for 48 weeks on low dose inhaled steroids

· These children were randomly assigned to continue on the same low dose or use a quintupled dose of inhaled steroids for 7 days at the early signs of loss of asthma control (yellow zone).

Yellow zone refers to the three zones of an Asthma Action Plan. When people are in the green zone, they are doing well without asthma symptoms, and they take their daily controller medicine if prescribed. When they are in the yellow zone, they are starting to have symptoms, and usually start taking their rescue medicine (albuterol). At this point, many clinicians recommend that patients increase their dose of inhaled steroids. When they are in the red zone, they are requiring more frequent albuterol use and need to call their clinician or go to the ED.

What did the authors find?

· The rate of severe asthma exacerbations (defined as requiring systemic steroids) was not significantly different between the two groups.

· The total steroid exposure was 16% higher in the group that received quintupling of inhaled steroids at the first sign of symptoms.

· The difference in linear growth between the group receiving the quintupling dose and the regular dose groups was -0.23cm/year, but this was not statistically significant (although the trend was there).

What does this mean?

· Increasing the dose of inhaled steroids four-fold during the early signs of an asthma flare did not reduce the rate of severe asthma exacerbations or other asthma outcomes.

· Quintupling the dose may be associated with decreased linear growth.

So, how has this study changed your practice? Or how has this changed your self-management?

#medications #sideeffects

DNA changes in cells of the immune system in childhood asthma

Today’s guest blog post is from Erik Melén, an Associate Professor at the Institutet of Environmental Medicine, Karolinska Institutet. He writes about a new study, just published in The Lancet Respiratory Medicine. He writes…

Why did we conduct our study?

Asthma is a respiratory disease caused by a chronic inflammation of the airways. An estimated 800,000 people have asthma in Sweden, about 50,000 of whom suffer so seriously that their everyday functioning is impaired. It is thought that asthma is caused by a combination of hereditary and environmental factors, but there are still many knowledge gaps to be filled. Epigenetics is an emerging research field that is focused on analyses of chemical modifications of the DNA. Epigenetics governs where and when different genes are active and DNA methylation is one of its most common regulatory mechanisms. In this study, we show that children with asthma have epigenetic DNA changes in certain cells of their immune system.

How did we conduct our study?

Collaborating with Professor Gerard Koppelman at the Groningen University in the Netherlands and others, we have conducted an extensive study of the epigenetic changes that can be related to asthma. The study included over 5,000 children from 10 European cohorts, including the Swedish birth cohort BAMSE, which is led by Erik Melén. The research is the result of a longer-standing collaboration with European researchers in the EU MeDALL (Mechanisms of the Development of Allergy) programme. In this project, we conducted an epigenome-wide association study (EWAS), which means that methylation levels at thousands of different loci across the genome was analyzed.

What did we find?

Our study shows that asthmatics have a lower degree of DNA methylation in certain immune cells than healthy controls, particularly in what are known as eosinophils, which play a critical part in the asthmatic inflammation. We identified DNA changes in 14 gene regions linked to children’s asthma, but these changes were not present at birth.

What do our findings mean?

We believe that our findings are key to understanding the disease mechanisms, even if we’ve not yet been able to show that the epigenetic changes actually cause asthma. Our results suggest that the lower DNA methylation in asthmatics increases activation of the immune cells, which play a central part in the development of asthma.

This is the largest epigenetic asthma study to date and we hope that our discoveries will give rise to better diagnostics and treatment possibilities. Influencing epigenetic regulation could be a new and interesting therapeutic strategy. We believe our findings can one day lead to improved diagnostics and treatment.

The study was primarily financed by the EU (the MeDALL project).

Link to the publication: http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(18)30052-3/fulltext?elsca1=tlxpr

#research #innovations

My visit to AAFA, leading organization for people with asthma and allergies

If you have asthma, you should know about AAFA. Last week, I had the opportunity to visit the Asthma and Allergy Foundation of America. AAFA is the leading organization for people with asthma and allergies.

I visited their office in Landover, Maryland, but they also have regional chapters in Alaska, Michigan, New England, and St. Louis. I had the opportunity to visit with AAFA’s new CEO, Kenny Mendez, who was on day 9 of his new job.

AAFA provides education for patients, caregivers, healthcare providers. They have online materials, printed materials, tools in Spanish, and so much more. The AAFA website is worth visiting.

· One education project of AAFA is Asthma Capitals. Every year, they rank the most challenging places to live in the U.S. for individuals with asthma by looking at 13 important factors.

· Another educational project is the State Honor Roll of Asthma and Allergy Policies for Schools, which ranks the states with the best public policies for people with asthma food allergies, anaphylaxis, and related allergic diseases in U.S. schools. Check out the interactive map to see how your state ranks!

AAFA provides advocacy for and support for public policies that will benefit people with asthma and allergies. For example, AAFA promotes access to affordable treatment and management of asthma and allergies.

AAFA conducts multiple research studies for asthma and allergic diseases including:

· Asthma Inhaler Design Survey where they invited over adult patients and parents of children with asthma to take an online survey. They found that 50% of relief inhalers were expired, 48% of relief inhalers were found to be empty. Adding a dose counter for inhalers would improve satisfaction with quick-relief inhalers (and these are now available).

· My Life With Asthma was an online survey that examined the challenges and experiences of those living with severe asthma. They found that 97% reported that asthma limited their everyday tasks, 83% reported that asthma affects their personal relationships, 48% used their quick-relief inhaler more than once a day, and 41% said they believed their asthma was so severe that there are no medicines that can make it better.

· The AFFORD (Asthma in Families Facing Out-of-Pocket Requirements with Deductibles) Study is the reason I was visiting AAFA. The principal investigator, Alison Galbraith, and I went to present some of our preliminary findings. The goal of this study is to better understand how different types of health insurance plans affect the experiences of people with asthma and their families.

As I said at the start, if you have asthma, you should know about AAFA.

Some photos of our visit...

#clinical

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