Asthma and COPD - Twitter summary from 2014 #ACAAI meeting

Dr Panettieri presented on COPD:

Fun Fact: The lung has the surface area of a tennis court.

Phenotypes in COPD: asymptomatic, ventilatory limited, muscle limited, gas exchange limited.

Systemic manifestation of COPD: Cardiovasc Disease, Osteoporosis, Respiratory Infections, Anxiety/Depression, Diabetes, Lung CA, Bronchietasis. COPD amplifies heart disease, manifested by arrhythmias, angina, acute MI, CHF, CVA, etc.

Osteoporosis/osteopenia is more frequent with greater spirometric severity in COPD.

There is a skeletal muscle dysfunction in COPD - these patients’ anaerobic threshold occurs much earlier leading to lactic acidosis. Lower BMI predicts increased mortality in COPD.

COPD patients have a high rate of depression and depression leads to non-adherence (important idea for other diseases too!!). Prevalence of depression in COPD patients is between 20 to 60%.

There are a variety of COPD biomarkers in sputum, BAL and blood, some more fruitful than others, to help identify at-risk patients.

Dr Panettieri pointed out the health problems associated with e-cigarettes including inhalation of formaldehydes. “COPD will develop if you smoke tobacco, marijuana, or cabbage".

Dr Phil Lieberman presented on "Asthma as COPD".

Lung remodeling is simple - Injury causes scarring that leads to aberrant healing that results in remodeling. “Easy peasy.”

Asthmatics as a group demonstrate an accelerated decline in FEV1 as they age compared with normal population.

Lung remodeling can begin very early in life, as early as 3 months of age. Dr Lieberman believes that irreversible damage to asthmatic lungs can be prevented, but notes that view is controversial. PFTs are not only way to see remodeling in severe asthmatics. CT scans can be used to follow airway wall thickness.

Duration, severity, bronchial reactivity, gender, eosinophil levels and IgE level all affect progression of remodeling. IgE and FEV1 in Tenor Study: FEV1 was lower in patients with high IgE across all age levels (IgE higher than 100 IU).

According to NHANES, allergic skin test reactivity correlated with a more rapid decline in FEV1 and FEV1/FVC.

Dr Bill Busse presented on Severe Asthma vs COPD - Therapeutic Dilemmas.

25% of patients with asthma smoke. 90% of COPD patients (in US) are smokers or ex-smokers.

Five clusters of obstructive lung diseases have been identified via genetic analysis - AJRCCM 2010;181:315.

"COPD-Asthma Overlap Syndrome" is a persistent airflow limitation with several features of both asthma and COPD. Treatment of Asthma-COPD Overlap Syndrome depends on features of the individual patient, Asthma more than COPD or COPD more than Asthma.

As many of 50% of older adults w/obstructive airways disease have overlapping diagnoses of asthma and COPD. HRCT, FENO and blood eosinophils can help distinguish asthma from COPD. COPD and asthma may be distinct entities in younger patients but as people age overlaps are more common and it associated with other comorbidities.

There is some debate now whether using ICS in treatment of mild COPD patients could put them at greater risk for respiratory infections.

Allergists should do more 6-minute walk tests in our COPD/asthma patients.

This is a Twitter summary from 2014 #ACAAI meeting. The post is a part of series. See the rest here: http://allergynotes.blogspot.com/search/label/ACAAI

The Twitter summary was made possible by @MatthewBowdish

Several allergists did a great job posting updates from the 2014 meeting of the #ACAAI. I used the website “All My Tweets” to review the tweets. For comparison, here are the tweets from previous #ACAAI meetings (scroll down the page for the past years): http://allergynotes.blogspot.com/search/label/ACAAI

Top 10 Allergy/Immunology Articles of the Year - Twitter summary from 2014 #ACAAI meeting

Top 10 A/I Articles of the Year by Mark O'Hollaren, who ended his tenure as moderator of these literature reviews:

1. Early life air pollution increases asthma risk in minority children - AJRCCM 188:309. Early-life NO2 exposure is associated with increased risk of childhood asthma in Latinos and African-Americans.

2. Mouse vs. cockroach antigen: Which is more highly assoc with poor asthma outcomes? - JACI 132: 830. In communities with both mouse and roach, mouse antigen appears more likely to be associated with poor asthma outcomes.

3. Daily intranasal fluticasone decreases children's growth velocity - JACI in Practice 2:421.Over 52 weeks, intranasal fluticasone had small decrease (0.27 cm/year) in growth velocity compared with placebo.

4. Food diversity in the first year of life decreases allergy risk - JACI 133:1056. There was an inverse association between diversity of food introduced and the subsequent development of asthma and food allergy.

5. Can you predict who will have biphasic anaphylaxis (reactions within 72 hrs without exposure to antigen)? - JACI in Practice 2:281. Biphasic anaphylaxis was associated with 1) prior anaphylaxis, 2) unknown trigger, 3) diarrhea and 4) wheezing.

6. Long-term safety and effectiveness of bronchial thermoplasty - JACI 132:1295. Data shows 5-year durability of benefit from BT with regards to asthma control and safety.

7. Are patients with asthma prone to bone loss? - Annals 4:426. Yes, asthma patients had bone loss. Even those not yet diagnosed with asthma had bone loss, authors suggested possible role for Vitamin D.

8. What percentage of kids outgrow asthma? - Pediatrics 132:e435. Only about 20% of kids outgrow their asthma by age 19.

9. Does local allergic rhinitis always evolve to systemic allergic rhinitis? - JACI 133:1026. Local allergic rhinitis is not just early allergic rhinitis, but is a separate entity with its own natural history.

10. Role for coronary mast cells during acute coronary syndrome? - Annals 112:309. One previous study has shown an association with allergen IT and a lower risk of acute MI. Endothelin-1 leads to mast cell degranulation and increased metalloproteinase-2 activity. Long-term endothelin-1 antagonist improved coronary endothelial function in patients with early atherosclerosis. Perhaps novel future CAD treatments could include a mast cell inhibitor?

This is a Twitter summary from 2014 #ACAAI meeting. The post is a part of series. See the rest here: http://allergynotes.blogspot.com/search/label/ACAAI

The Twitter summary was made possible by @MatthewBowdish

Several allergists did a great job posting updates from the 2014 meeting of the #ACAAI. I used the website “All My Tweets” to review the tweets. For comparison, here are the tweets from previous #ACAAI meetings (scroll down the page for the past years): http://allergynotes.blogspot.com/search/label/ACAAI

Literature review: Food allergy - Twitter summary from 2014 #ACAAI meeting

Dr Vivian Hernandez-Trujillo discussed Food and Additives Allergy.

Sustained unresponsiveness to peanut in subjects who have completed peanut oral IT - JACI 133: 468. First study to show sustained unresponsiveness (4 weeks) after peanut OIT was stopped.

Peanut, milk and wheat intake during pregnancy is associated with reduced allergy and asthma in children - JACI 133: 1373. Maternal peanut intake in 1st trimester was linked to almost 50% reduction in odds childhood peanut allergy. Maternal milk intake in 1st trimester was linked to 15% decreased odds childhood asthma and allergic rhinitis. Maternal wheat intake in 2nd trimester was associated with "decreased atopic dermatitis". A window of exposure during early life may exist where food tolerance develops.

Skin prick test (SPT) responses and sIgE levels as predictors of peanut, egg and sesame allergy in infants - JACI 2013; 132: 874. SPT was more precise than sIgE at predicting sesame, egg and peanut allergy in infants with NO history of reactions. No SPT threshold exists for 95% PPV for BAKED egg. No sIgE threshold exists for 95% PPV sesame allergy or baked egg allergy.

IgE-targeted testing vs. 6 food elimination diets for EoE - Allergy 69:936. Serum specific IgE were better at detecting offending agent than percutaneous testing (prick and atopy patch). 100% of patients with positive milk sIgE had reactivation of disease at time of reintroduction. A remission occurred in almost 3/4 pts with sIgE-ED, comparable to six food elimination diet. This was a study of adults with EoE.

This is a Twitter summary from 2014 #ACAAI meeting. The post is a part of series. See the rest here: http://allergynotes.blogspot.com/search/label/ACAAI

The Twitter summary was made possible by @MatthewBowdish

Several allergists did a great job posting updates from the 2014 meeting of the #ACAAI. I used the website “All My Tweets” to review the tweets. For comparison, here are the tweets from previous #ACAAI meetings (scroll down the page for the past years): http://allergynotes.blogspot.com/search/label/ACAAI



Food allergy management in 4 steps (click to enlarge the image).

Literature review: Immunotherapy - Twitter summary from 2014 #ACAAI meeting

Dr Hal Nelson discussed new literature on immunotherapy.

Comparison of SLIT and SCIT - Clin Exp Allergy 44:417. Take home message: SCIT shows significant and more profound effect than SLIT by symptoms and humoral biomarkers.

AAAAI/ACAAI Study of SCIT 2008-2012 - JACI in Practice 2014;2:161. From 2008-12, 27-49% of AAAAI/ACAAI members responded to surveys, representing 23.3 million injection visits. In Bef 2002 study, there were 3.4 fatal reactions per year from SCIT, from 2008-2012 there was just 1 fatal reaction from SCIT. That was in an asthmatic with comorbidities. Dr Nelson laments that the survey participation rate has declined in recent years.

Esophageal hypereosinophilia induced by grass SLIT - JACI 133: 1482. A 23-yo male was on previous HDM SLIT but had dysphagia 1 month after starting grass SLIT tablet, biopsy showed 18-24 eos/hpf. Once grass SLIT stopped (and patient continued HDM SLIT), symptoms and biopsy findings normalized. There was another case of EoE with another SLIT for birch/alder/hazelnut - Case Rep GI 7:363.

House Dust Mite (HDM) sublingual tablet from Denmark - Mosbech JACI. Dose unknown (trade secret?) but looked at ICS use and asthma control. Only highest dose of the tablet ("6 DU") significantly reduced dose of ICS but other study parameters did not differ.

Ragweed SLIT for Allergic rhinoconjunctivitis - JACI 133:751. This is a Phase III study using product with a higher dose than ragweed tablets or other forms of SLIT. This liquid ragweed product reduced symptoms/medication scores by 20% and was associated with only 12% incidence of local adverse reactions.

This is a Twitter summary from 2014 #ACAAI meeting. The post is a part of series. See the rest here: http://allergynotes.blogspot.com/search/label/ACAAI

The Twitter summary was made possible by @MatthewBowdish

Several allergists did a great job posting updates from the 2014 meeting of the #ACAAI. I used the website “All My Tweets” to review the tweets. For comparison, here are the tweets from previous #ACAAI meetings (scroll down the page for the past years): http://allergynotes.blogspot.com/search/label/ACAAI


Mechanisms of allergen-specific immunotherapy (click to enlarge the image). The diagram is based on: Mechanisms of allergen-specific immunotherapy. Akdis CA, Akdis M. J Allergy Clin Immunol. 2011 Jan;127(1):18-27.

Literature review: drug allergy, immunotherapy and anaphylaxis - Twitter summary from 2014 #ACAAI meeting

Dr Montanaro discussed updates on drug allergy, immunotherapy and anaphylaxis:

1. Consequences of PCN allergy - Macy JACI 2014. Hospital costs of PCN allergy alone may account for $20M/year in just one large hospital system. -- "It would be reasonable to test all presurgical patients who claim to be allergic to penicillin if these patients will be needing perioperative antibiotic therapy. There are a lot of people out there who report a penicillin allergy and are unnecessarily being prescribed a wider-spectrum antibiotic than they really need. If you can work in a multidisciplinary capacity with your colleagues in surgery and anesthesia to come up with a system in which these patients can come to the allergy department as part of their preop evaluation, collectively we can reduce the use of these broader-spectrum antibiotics. More important, we can let these patients know that they're not allergic, so we really can potentially open up their antibiotic armamentarium" http://buff.ly/1xK7Yjx

2. PEN G testing in children - Picard, Annals 2014. Negative Predictive Value of Pen G skin test and challenge was 95%. This compares favorably with protocols using PPL and MDM. The cost of NOT testing for PCN allergy is high!

3. PPI Allergy - Bose, Annals, 2013. Authors reviewed 39 publications and 119 cases of allergy to five different PPI, omeprazole was the most common. Most frequent PPI reactions were: urticaria [54%], angioedema [38%], hypotension [23%] and SOB [20%]. Tested as follows: SPT 20-40mg/ml, ID 0.04-40mg/ml. Omeprazole cross-reacts with pantoprazole. They found 3 different cross-reactivity patterns with PPIs: omeprazole cross-reacts with all, lansoprazole cross-reacts with rabeprazole but not any others.

4. ACEI/VIT - Stoevesandt Clin Exp All. It's important to check serum tryptase in all patients undergoing workup for venom allergy to rule out indolent mastocytosis. ACEI or beta-blocker prescription was not associated with increased risk of systemic reaction, but the study was not powered to answer b-blocker question.

5. Fire Ant Rush IT - Arseneau, Annals, 2013. RIT is safe/efficacious in most patients, it may improve adherence, premed decreases systemic reactions, but there was higher than normal build-up.

6. A Long Study of Stinging Insect Anaphylaxis - Rudders, Annals 2013. Only 70% of patients with stinging insect allergy fill their epinephrine prescriptions.

7. Anaphylaxis in America - Wood, JACI, 2014. Anaphylaxis is common (1 in 20 adults), 50% never received epi, the majority have life-threatening reactions. Anaphylaxis represents a huge opportunity for clinical improvement.

This is a Twitter summary from 2014 #ACAAI meeting. The post is a part of series. See the rest here: http://allergynotes.blogspot.com/search/label/ACAAI

The Twitter summary was made possible by @MatthewBowdish

Several allergists did a great job posting updates from the 2014 meeting of the #ACAAI. I used the website “All My Tweets” to review the tweets. For comparison, here are the tweets from previous #ACAAI meetings (scroll down the page for the past years): http://allergynotes.blogspot.com/search/label/ACAAI



Drug allergy management in 5 steps (click to enlarge the image).
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