Single maintenance and reliever therapy (SMART) did not work very well in asthma patients

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The use of a combination inhaler containing budesonide and formoterol as both maintenance and quick relief therapy (SMART) has been recommended as an improved method of using inhaled corticosteroid/long-acting beta agonist (ICS/LABA) therapy. Published double-blind trials show that budesonide/formoterol therapy delivered in SMART fashion achieves better asthma outcomes than budesonide monotherapy or lower doses of budesonide/formoterol therapy delivered in constant dosage.

However, it has been reported that only 17% of SMART-treated patients are controlled. In seven trials of 6–12 months duration, patients using SMART:

- used quick reliever daily (average 0.92 inhalations/day)
- awakened with asthma symptoms once every 7–10 days (11.5% of nights)
- suffered asthma symptoms more than half of days (54% of days)
- had a severe exacerbation rate of one in five patients per year (average 0.22 severe exacerbations/patient/year)

These poor outcomes may reflect the recruitment of a skewed patient population.

Although the long-term consequences of SMART therapy have not been studied, its use over 1 year has been associated with significant increases in sputum and biopsy eosinophilia.

At present, there is no evidence that better asthma treatment outcomes can be obtained by moment-to-moment symptom-driven use of ICS/LABA therapy than conventional physician-monitored and adjusted ICS/LABA therapy.

References:

Single maintenance and reliever therapy (SMART) of asthma: a critical appraisal. Thorax 2010;65:747-752 doi:10.1136/thx.2009.128504.
Children with mild persistent asthma should not be treated with rescue albuterol alone - add ICS PRN - Lancet, 2011.
Single inhaler therapy in asthma (SMART) linked to poor day-to-day control of symptoms and increasing inflammation. Clin Exp Allergy. 2012 Jan 18.
Image source: Combination formulation containing budesonide and formoterol - unopened Symbicort Turbuhaler (left) and opened (middle and right), Wikipedia, public domain.

Dust mite allergen avoidance

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Dust mite allergen avoidance. The main allergen is in the dust mite feces. Use 3 control measures for 3-6 months to see an effect on the allergy symptoms (click to enlarge the image).

House dust mite sensitization in toddlers predicts wheeze at age 12 years (JACI, 2011).

References:

The efficacy of dust mite covers and hot water wash environmental control procedures http://goo.gl/CvIIk

Dust mite-impermeable mattress covers alone are not very helpful - a complex approach with 3-4 measures is needed http://goo.gl/nr3TW -- House dust mite impermeable bedding as an isolated intervention is unlikely to offer benefit (Allergy, 2011).

Millions suffer 'home fever' as allergy epidemic begins to bite - dust mites account for 58% of household allergies. The Independent, 2011.

Millions of people are 'allergic to their own home' (dust mites) http://goo.gl/3DOW6 - Good review of the evidence by NHS.

27% of individuals in the United States are sensitive to dust mite. AAAAI Ask the Expert, 2011.

Bleach Baths Improve Atopic Dermatitis - How To Use Them?

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Staphylococcus aureus colonization

Staphylococcus aureus ("Staph") colonization and infection is a common complication of atopic dermatitis (AD), due to defective epidermal barrier and decreased antimicrobial peptides. Also, Staphylococcus aureus superantigens worsen the inflammation of atopic dermatitis.

Comprehensive approach to atopic dermatitis care

The diagram below shows the comprehensive approach to atopic dermatitis care:

1. Exacerbation management. The top part of the diagram includes the treatment of exacerbations (flares) with topical steroids or steroid-sparing cream (for example, Elidel).

2. Maintenance. The bottom part of the diagram shows the maintenance treatment with daily bath, twice a day moisturizers, and weekly diluted bleach baths.

Atopic Dermatitis Treatment - Illustrated (click here for full size image).

Evidence supporting the elimination of Staphylococcus aureus colonization

In a 2009 study, 31 children (aged months–17 years) with AD and signs of bacterial skin infection received 2 weeks of cephalexin (an oral antibiotic). Then, the treatment group bathed twice weekly in dilute bleach (0.5 cup of bleach to 40 gallons of bathwater) for 5 to 10 minutes.

At baseline, S. aureus was cultured from 87% of skin and 81% of nares (7% of skin bacteria and 4% of nares bacteria were methicillin resistant [MRSA]).

In the study, all patients received cephalexin at 50 mg/kg per day (maximum of 2 g/day), divided into 3 daily doses, for 2 weeks to treat their Staphylococcal infections. Patients were instructed to add either 0.5 cup of 6% bleach (final concentration: 0.005%; treatment arm) or water (placebo arm) to a full bathtub of water (40 gallons). The amount of administered bleach solution or water was adjusted by the family on the basis of the bathtub size and estimated height of bathtub water. Patients were instructed to bathe in the dilute bleach bath or placebo bath for 5 to 10 minutes twice weekly.

Irrigation with dilute bleach was first used for infected wounds and as a perioperative antiseptic during World War I. The concentration used in this study was only 0.005%, more dilute than swimming pool water. Clorox (R) bleach concentration is is 5.95% sodium hypochlorite.

The Eczema Area and Severity Index scores body sites submerged in the dilute bleach baths decreased at 1 and 3 months, in comparison with placebo-treated patients. Chronic use of dilute bleach baths with intermittent intranasal application of mupirocin ointment decreased the clinical severity of atopic dermatitis in patients with clinical signs of secondary bacterial infections.

How To Use Diluted Bleach Baths To Treat Atopic Dermatitis

- Add 1/2 cup (118 milliliters, 0.5 cup) of bleach to a 40-gallon (151-liter) bathtub filled with warm water

- Soak the affected areas of skin for 5-10 minutes

- Dry your skin and apply a thick layer of moisturizer (Eucerin in AM, Aquafor in PM)

- Take a bleach bath no more than twice a week

A Spray Bottle for Diluted Bleach Application

A spray bottle can be used instead of the bleach bath. Add one (1) milliliter of bleach to 1.5-liter bottle with warm water. Transfer to a spray bottle. Spray the affected areas of skin at leave it on for 5-10 minutes. Avoid spraying the face and stay away from the eyes, nose and mouth. Follow the directions above.

References

Treatment of Staphylococcus aureus Colonization in Atopic Dermatitis Decreases Disease Severity. PEDIATRICS Vol. 123 No. 5 May 2009, pp. e808-e814 (doi:10.1542/peds.2008-2217).

Bleach Baths for Atopic Dermatitis. Journal Watch.

What is a bleach bath? Can it treat chronic eczema symptoms? MayoClinic.com.

Colonization of S. aureus in early childhood eczema (72.7%) originates from childrens' own noses, not from mothers http://goo.gl/0fptY
Extracellular vesicles derived from Staphylococcus aureus induce atopic dermatitis-like skin inflammation http://goo.gl/Evqr

Comments from Twitter:

@rlbates My mom gave us bleach baths as kids to get rid of ticks esp the minute seed ticks. It worked. Just a small amt in the bath water.

Lung Plush Toy from "I Love Guts: I Lung You!" and Amazon.com

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"Lung Plush from I Love Guts: I Lung You!" are available from Amazon.com Toys & Games. These toys look cute and are generally found to be interesting by the pediatric patients.

More info here: Lungs Plush Toy from "I Heart Guts, Love Your Insides":

This adorable, super-soft, 9" x 9" lung is perfect for cuddlin', and makes a great gift for anyone who needs some extra breathing power. Comes with a handy tag telling you all about your lungs. Safe for all ages. Designed in California, made in China.

I already have the dust mites by GIANTmicrobes from Amazon.

Role of acetaminophen (paracetamol, Tylenol) in asthma

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Paracetamol use represents a putative risk factor for the development of asthma. There is epidemiological evidence that the risk of asthma may be increased with exposure to paracetamol in the intrauterine environment, infancy, later childhood and adult life.

A dose-dependent association has been observed in different age groups worldwide. An association has also been shown between paracetamol use in both rhinoconjunctivitis and eczema.

There is biological plausibility with paracetamol use leading to decreased glutathione levels resulting in increased oxidant-induced inflammation and potentially enhanced T-helper type 2 responses.

Patterns of paracetamol use might explain the worldwide variation in the prevalence of asthma, particularly the high rates in English-speaking countries, which have high per capita prescription and over-the-counter use of paracetamol.

An association may exists between the international trends of increasing paracetamol use and increasing prevalence of asthma over recent decades.

Randomized-controlled trials (RCTs) are required to determine if there is a causative association.

It is too early to draw any conclusions at this point and I would not recommend a change in the use of acetaminophen for upper respiratory tract infections with fever, pain, or for other indications.

References:
The role of paracetamol in the pathogenesis of asthma. Clin Exp Allergy. 2010 Jan;40(1):32-41. Authors: Farquhar H, Stewart A, Mitchell E, Crane J, Eyers S, Weatherall M, Beasley R.
http://www.ncbi.nlm.nih.gov/pubmed/20205695?dopt=Abstract
Paracetamol use does not increase the risk of asthma - BMJ http://goo.gl/wtKZ
Acetaminophen no asthma trigger after all. http://goo.gl/kHDu

Acetaminophen use may represent an important risk factor for the development and/or maintenance of asthma, rhinoconjunctivitis, and eczema in adolescent children. American Journal of Respiratory and Critical Care Medicine Vol 183. pp. 171-178, (2011).
Paracetamol (acetaminophen) and Antibiotics in Childhood and Later Wheezing/Asthma: Association or Causation? Medscape, 2011.
"Acetaminophen phobia" is not warranted until we see confirmatory studies in children with asthma. Journal Watch, 2012.

Children with severe asthma are at high risk of developing COPD

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Subjects who were classified as having severe asthma in childhood had an adjusted risk of COPD of 31.9 times that of children without asthma. Interestingly, children with mild asthma were not at increased risk of developing adult obstructive lung disease.

Importantly, this study was performed on a group of children recruited in the 1960s when anti-inflammatory treatment was not available. Studies to date suggest that anti-inflammatory medications do not alter the natural progression of mild childhood asthma, but there are no studies performed in those children with severe asthma.



Severe asthma - differential diagnosis and management (click to enlarge the image).

References:

Children with severe asthma at increased risk of developing COPD. EurekaAlert.

An approach to recalcitrant, severe asthma - AAAAI Ask the Expert, 2011.
Action plan is a key component of self-management programs in patients with COPD. Thorax, 20111.

Atopic Dermatitis Treatment - Illustrated

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Atopic Dermatitis Treatment - Illustrated (click here for full size image).

Related:

The Return of Whooping Cough (video)

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From ABC Chicago:

Whooping cough is now an epidemic in California, sickening thousands of people and killing eight babies. Smaller outbreaks have been reported in other states, including Illinois and Indiana.

Some experts blame a decline in childhood vaccines. But an uptick in the disease may have more to do with teens and adults who don't realize they are no longer protected.



Differential diagnosis of cough, a simple mnemonic is GREAT BAD CAT TOM. Click here to enlarge the image: (GERD (reflux), Laryngopharyngeal Reflux (LPR), Rhinitis (both allergic and non-allergic) with post-nasal drip (upper airway cough syndrome), Embolism, e.g. PE in adults, Asthma, TB (tuberculosis), Bronchitis, pneumonia, pertussis, Aspiration, e.g foreign body in children, Drugs, e.g. ACE inhibitor, CF in children, Cardiogenic, e.g. mitral stenosis in adults, Achalasia in adults, Thyroid enlargement, e.g. goiter, "Thoughts" (psychogenic), Other causes, Malignancy, e.g. lung cancer in adults).

Immunoglobulin therapy during the last 20 years and its effect on infections in common variable immunodeficiency (CVID)

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15% off petite scrubs with code "petit_55cv"

Common variable immunodeficiency disorders (CVIDs) are the most common forms of symptomatic primary antibody failure in adults and children. The most common immunodeficiency is a IgA deficiency. Replacement immunoglobulin is the standard treatment for CVID, although there are few studies on optimal dosages and target trough IgG levels required for infection prevention.

Data, collected prospectively from a cohort of 90 patients with CVIDs from 1 center over a follow-up period of 22 years, was analyzed. A smaller group of patients with X-linked agammaglobulinemia was analyzed for comparison.

Patients with a CVID had a range of trough IgG levels that prevented breakthrough bacterial infections (5-17 g/L); viral and fungal infections were rare.

Doses of replacement immunoglobulin to prevent breakthrough infections ranged from 0.2 to 1.2 g/kg/mo. Those with proven bronchiectasis or particular clinical phenotypes required higher replacement doses.

Patients with X-linked agammaglobulinemia showed a similar range of IgG levels to stay infection-free (8-13 g/L).

The authors concluded that the goal of replacement therapy should be to improve clinical outcome and not to reach a particular IgG trough level.

Since 1990s, no transmission of infectious diseases have been reported from U.S.-licensed IVIG products.

References:
Infection outcomes in patients with common variable immunodeficiency disorders: Relationship to immunoglobulin therapy over 22 years. Lucas M, Lee M, Lortan J, Lopez-Granados E, Misbah S, Chapel H. J Allergy Clin Immunol. 2010 May 12.

Image source: Wikipedia.

Does Obesity Increase Risk of Atopy?

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Literature on the association between obesity and atopy has been inconsistent. This study included 1,997 residents aged 18-79 years in Canada. Body mass index (BMI) and waist circumference (WC) were measured. Allergy skin tests were conducted to determine atopic sensitization.

Prevalence of one or more positive skin tests for atopy was:

- 33.3% among those with a BMI of at least 30.0

- 28.2% among those with a BMI of 25.0-29.9

- 27.3% among those with a BMI of less than 25 (p = 0.003)

The odds ratio for atopy among those with a BMI of at least 30.0 versus those with a BMI of less than 25.0 was 1.51. WC was also significantly associated with the prevalence of atopy in both sexes.

The data demonstrated an association between obesity, defined either by BMI or by WC, and atopy.

References:
Association between Obesity and Atopy in Adults. Chen Y, Rennie D, Cormier Y, Dosman J. Int Arch Allergy Immunol. 2010 Jun 17;153(4):372-377.

Image source: Wikipedia, public domain.