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Pulmonology Conference Briefing
2007 - American Academy of Allergy Asthma and Immunology
By The American Academy of Allergy Asthma and Immunology
Feb 23, 2007 - 3:36:25 PM

The American Academy of Allergy Asthma and Immunology - 63rd Annual Meeting was held in San Diego, February 23-27, 2007. The following is a briefing of some of the articles presented at the conference.

Allergic Rhinitis

SAN DIEGO-Allergic fungal sinusitis (AFS) constitutes a distinct form of chronic rhinosinusitis (CRS), according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Patricia S. Hutcheson, Saint Louis University Medical School, Saint Louis, MO, and colleagues, studied 84 CRS patients with nasal polyps. If these patients had positive fungal cultures or positive fungal stains from surgical specimen, they were designated as AFS, with the remaining 18 patients as CRS.

Researchers analyzed these two groups and found that AFS patients demonstrate an enhanced IgE and IgG immune response to fungi. This clearly differentiates AFS from other forms of CRS.

Non-allergic triggers affect patients with allergic rhinitis
Patients with allergic rhinitis have more non-allergic triggers than normal controls without allergic rhinitis, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Dennis Shusterman, MD, MPH, University of Washington, Seattle, WA, and colleagues, recruited 60 patients ranging from age 19 to 68 years and studied their chemosensory function in relation to their age, gender and allergic rhinitis status.

Researchers found that the majority of patients who reported reacting to more than three non-allergic triggers had allergic rhinitis, with 42% of patients with allergic rhinitis reporting greater than three triggers, compared with only 3% of controls. Subjects over 35 years of age were more likely to report one or more non-allergic triggers, particularly tobacco smoke.

This study demonstrates that patients with allergic rhinitis often react to non-allergic symptom triggers (such as cold air, perfumes and colognes, cigarette smoke, household cleaning products, and exercise) in addition to responding to allergens, and that older patients are more likely to report at least one non-allergic symptom trigger.

Advances in allergic rhinitis can improve sleep disordered breathing in children
Adequate treatment and elimination of indoor allergens such as cockroach, mouse or rat, may significantly improve sleep-disordered breathing (SDB), according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Neeti Gupta, MD, Long Island College Hospital, Brooklyn, NY, and colleagues, evaluated patients, aged 2-18 years, for allergic rhinitis. Next, skin prick testing to aeroallergens, including inner-city allergens such as rat, cockroach, and mouse, were performed. A validated Pediatric Sleep Questionaire (PSQ) was used to determine if treatment with an intranasal steroid improves SBD. After six weeks of treatment, PSQ results showed a clinical improvement in SBD.

Researchers concluded that children who have increased allergic rhinitis-related nasal obstruction leading to sleep-disordered events, may significantly improve SDB with adequate treatment. And in inner-city children, elimination of indoor allergens that contribute to allergic rhinitis symptoms may further improve SBD.

Research shows lack of physician-patient communication in treatment of allergic rhinitis
The prevalence of ocular symptoms and sleep disturbances associated with allergic rhinitis is not fully observed by physicians, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Michael Schatz, MD, MS, FAAAAI, Kaiser Permanente Medical Center, San Diego, CA, and colleagues, asked physicians to complete a patient record form including questions on symptoms of their patients with allergic rhinitis. These patients were also asked to complete a record form with questions on their symptoms.

The study found that the physicians, either primary care or specialist, rated fewer patients as having severe allergic rhinitis compared with the patients' rating of their own disease severity. They also found that itchy, red, watery eyes and trouble sleeping were more often reported by patients than physicians.

This study shows that treatment of allergic rhinitis and physician-patient communication about allergic rhinitis should be improved and would probably benefit from an easy to use patient-based measure of rhinitis control.

Origins of asthma and allergies during early childhood

SAN DIEGO-Children who have a wheezing rhinovirus illness during infancy are likely to develop childhood asthma by age six, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Kathleen A. Roberg, RN, MS, University of Wisconsin School of Medicine and Public Health, Madison, WI, and colleagues sought to determine if rhinovirus (RV) wheezing illnesses in the first year of life might influence the development of asthma later on in childhood, by evaluating respiratory tract symptoms and the presence/absence of wheezing of children. These children were then evaluated for asthma at age six years.

The study showed that children who had a wheezing RV illness during infancy are significantly more likely to be diagnosed with asthma at age six than children who did not. Children with non-wheezing illnesses with RV predicted risk of recurrent wheeze at age three years, but not asthma at age six years.

Respiratory illnesses during infancy influence development of asthma in children
Respiratory illnesses during infancy influence the development of asthma in early childhood but do not affect immunologic or clinical markers of atopy, according to a new study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Rochelle A. Grabher, University of Wisconsin School of Medicine and Public Health, Madison WI, and colleagues tested the hypothesis that exposure to infections in infancy may protect against the development of asthma. They examined the influence of viral respiratory illnesses during infancy on the development of asthma and other markers of atopy by age six.

Of the children studied, 27 experienced frequent moderate to severe illnesses (MSI) in year one, and 54 children had no MSI. This frequency was then compared to results of skin prick tests performed at 5-year study visits, RAST and the number of children diagnosed with active atopic dermatitis and asthma at age six years. Results showed that children with MSI during infancy had a higher incidence of asthma at age six years relative to those with no illnesses. No significant differences were found between children with frequent MSIs and children with no MSIs relative to the incidence of positive skin prick tests, positive RAST or active atopic dermatitis.

This shows that frequent moderate to severe respiratory illnesses during infancy significantly influence the development of asthma in early childhood but do not affect immunologic or clinical markers of atopy.

Children in urban areas, not receiving proper asthma treatment
Many children in urban areas are not receiving comprehensive asthma treatment, including management of allergies and education on avoidance of household allergens, according to new research presented today at the 2007 AAAAI Annual Meeting in San Diego, CA.

Jeanette A. Stingone and Luz Claudio of Mount Sinai School of Medicine in New York, nalyzed parent-report questionnaires distributed in 26 randomly selected New York City public elementary schools. The questionnaire included items on sociodemographics, health insurance, asthma diagnosis, allergy diagnosis and testing, use of medical services, medication use, and presence of environmental triggers.

Results showed that less than half of the asthmatics, 47.3%, had received a diagnosis of allergies from their physician. An allergy diagnosis was more common among whites, children from higher income households, and children whose questionnaires were completed in English. Of the asthmatic children with an allergy diagnosis, only 54.9% reported allergy testing. Allergy testing was found to be associated with increased treatment and/or prevention of allergy symptoms as well as decreased exposure to environmental triggers in the home.

The study concluded that urban children, especially those with public insurance, are not receiving comprehensive asthma treatment and interventions which are key to reducing asthma morbidity in urban areas.

Children with asthma at age six years have higher rates of allergic sensitization during infancy
Children who develop asthma by age six years have increased rates of allergic sensitization during infancy and early childhood, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Christopher J. Tisler, MT, (ASCP), University of Wisconsin School of Medicine and Public Health, Madison, WI, and colleagues, examined the timing and pattern of the development of allergic sensitization in the first years of life to asthma at age six years by evaluating children at ages one, three, five and six years. Researchers found that children with sensitization to any allergen at these ages, were more likely to have developed asthma at age six years. The timing of the increased incidence of sensitization appeared for both foods and aeroallergens during infancy.

The pattern of overall prevalence rates for sensitization in children with asthma remained relatively constant, but the pattern of specific allergen sensitization and its relationship to asthma prevalence at age six did not.

This study shows that children who develop asthma by age six years have increased rates of allergic sensitization as early as infancy, and the specificity of this sensitization process appears to follow a distinct developmental pattern in later childhood.

Response to environmental allergens used as markers of severe asthma for inner-city children with asthma
Markers of severe asthma for inner-city children with asthma can be determined by using specific IgE levels and prick skin test wheal sizes according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Julie Wang, MD, Mount Sinai Medical Center, New York, NY, and colleagues investigated the association between the degree of sensitization to environmental allergens and asthma morbidity in inner-city asthma patients.

Statistical analyses were performed on 512 random serum samples to determine the association between sensitization to certain allergens and asthma morbidity.

They found that sensitization to environmental allergens and total IgE correlated with increased healthcare and medication use, but not with reported symptoms of wheeze. Sensitization with exposure to cockroach was associated with increased asthma morbidity.

This study concludes that specific IgE levels and prick skin test wheal sizes to environmental allergens can serve as markers of severe asthma for inner-city children with asthma.

Poor asthma control in children found with increased controller medication use
Despite increased communication between primary care providers (PCPs) and parents of children with asthma, children with persistent asthma continued to experience poor asthma control even with increased controller medication use, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Arlene Manns Butz, ScD, RN, CPNP, Johns Hopkins University, Baltimore, MD, and colleagues studied caregivers of 75 children with persistent asthma over a period of six months. Asthma medication use, health care utilization and level of asthma control were determined via parent interview.

Researchers found that children who received the asthma communication education intervention (ACE) had significantly higher controller medication use at 86% vs 56%. However, more ACE parents reported their child's asthma was out of control at some, a lot or all of the time.

This shows that an asthma communication intervention was associated with increased controller medication use but not child asthma control or decreased quick relief medication use. Despite adequate exposure to PCP, this group of high risk children continued to experience poor asthma control even with increased controller medication use.

Use of rescue medications indicates need for closer monitoring of children with asthma
A need for closer monitoring of children with persistent asthma is necessary, as they are not achieving adequate asthma control, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Carrie L. Vibbert, RN, University of Maryland School of Medicine, Baltimore, MD, and colleagues examined monthly prescription fill patterns for controller (CM) and rescue (RM) medications to determine if conflicting perceptions of asthma management were present.

The team collected self-reported caregiver asthma management perceptions, healthcare utilization and pharmacy data from 67 school-aged minority children with persistent asthma. Results showed that children who used controller medications filled oral corticosteroids (OCS) more often than non-controller medication users.

These results show that continued use of rescue medications despite controller medications indicates a need for closer monitoring of children with persistent asthma.

Food Allergy

SAN DIEGO-Parents of children with food allergies underutilize EpiPen when there is an emergency due to lack of empowerment, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Jennifer S. Kim, Children's Memorial Hospital, Chicago, IL, and colleagues, surveyed parents of 240 children with a physician-diagnosed food allergy, an EpiPen prescribed, and living in a low-income zip code. Surveys were returned by 50% of subjects. Factors correlating with comfort included prior EpiPen administration and empowerment.

This study shows that parents of inner-city children with food allergies should be better prepared for an emergency. Increasing parental knowledge of proper EpiPen use may increase the comfort level among suburban parents. However, knowledge was not a significant contributing factor that increased comfort of EpiPen use among inner-city parents. In both urban and suburban parents, however, empowerment was a significant factor of comfort, showing that increasing empowerment in parents is an important way to increase comfort.

New research in desensitization of egg allergy
Children with egg allergy may be safely desensitized, or have a reduced sensitivity through oral desensitization therapy, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Masayuki Akashi, National Center for Child Health and Development, Tokyo, Japan, and colleagues, aimed to investigate the efficacy and safety of oral desensitization therapy in children with egg allergy in Japan.

Thirteen children ages 4 to 8 years old, diagnosed with egg allergy were admitted to the study. Oral desensitization was performed with increasing dose of egg. Eleven of 13 children (85%) could eat 14g of egg during six month period. Two of the children tolerated 2g and 7g of egg after 6 months. This study shows that some children can be safely desensitized from egg allergy, and the others can have a reduced risk of critical allergic reaction with accidental ingestion of egg in all patients.

Predicting remission of peanut allergies in children
It is possible to predict remission of peanut allergies in children, according to a study conducted at Murdoch Children's Research Institute in Australia. Melbourne doctor, Katie J.Allen, MD, PhD will present findings of the research at the 2007 AAAAI Annual Meeting in San Diego, CA.

Dr. Allen and team identified patients with peanut sensitivity and followed them for up to 9 years to determine the clinical predictors of remission. By age 5 more than 21 % had experienced remission to peanut allergens.

Significantly, the patients who did not remit, when compared to those who remitted had a smaller peanut skin prick test wheal size at four years of age as well as a lower frequency of tree nut and sesame seed sensitization and asthma. According to Dr. Allen this shows that a fall in skin prick test wheal diameter can predict remission of peanut allergy.

Oral immunotherapy for peanut allergy in children is safe and effective
Peanut oral immunotherapy is safe and effective for decreasing the risk of a significant reaction with peanut ingestion, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Scott David Nash, MD, Duke University Medical Center, Durham, NC, and colleagues, studied children with a clinical history of peanut allergy. These children went through three phases: a modified rush initial day of multiple doses; a build up phase of daily doses; and a daily maintenance phase of up to 18 months. An open food challenge to peanut flour was performed at the end of the study. Seven of the eight children that completed the study tolerated the maximum dose of peanut flour (7.8 g).

This study concludes that peanut oral immunotherapy is safe and effective for decreasing the risk of a significant reaction with peanut ingestion.

Children with food allergen sensitivity may have effects on lung function even after taking aeroallergen sensitization into account
Food allergen sensitization in children may affect lung function even after taking into account aeroallergen sensitization, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Rajesh Kumar, MD, FAAAAI, Division of Allergy, Children's Memorial Hospital, Chicago, IL, and colleagues sought to determine whether food allergen sensitization in children is associated with lung function independently of aeroallergen sensitization. Researchers analyzed 919 children aged 10-17 years. Food allergen sensitization was determined by skin testing.

The study found that food allergen sensitization was associated with lower lung function in boys even after taking the effect of aeroallergen sensitization into account. However, the lower measures of lung function were not associated with airway obstruction. Along with the fact that the food allergen sensitized children had lower body mass index measurements, this finding may imply a developmental effect of food allergen sensitization on lung growth and development.

Early exposure to peanut is a risk factor for development of peanut allergy
Early exposure to low levels of peanut in human breast milk or in utero, may be a significant risk factor for the development of peanut allergy in infancy, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Anne Des Roches, MD, Allergy Section, Hospital Sainte-Justine, Montreal, PQ, Canada, and colleagues, analyzed the mothers of 403 infants between 1998 and 2005. The mothers underwent a detailed questionnaire about breastfeeding, maternal diet during pregnancy and breastfeeding, infant diet, environmental exposure to peanut and family atopic status.

Results of the questionnaires were then compared for age, sex, maternal age and maternal education level. Rate and duration of breastfeeding were similar in all groups, however the ingestion of peanut was clearly increased during breastfeeding and the pregnancy in the mothers. These results show that early exposure to low levels of peanut in breast milk or in utero, may be a significant factor for the development of peanut allergy in infancy.

Siblings of peanut allergic children, more likely to be allergic
Children with a peanut allergic sibling are more likely to be allergic to peanut, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA. Saiful Huq, University of Manitoba, Winnipeg, MB, Canada, and colleagues, studied 514 children, born in 1995 in Manitoba, Canada, who were given a questionnaire. The likelihood of peanut allergy in siblings was then determined based on parental report of allergist assessment and dispensed EpiPen.

They found that 32 (6.6%) of the children were peanut allergic. There was a total of 15 siblings with peanut allergy. Of these, 4 (8%) of the siblings had the index child with a peanut allergy and 11 (1.3%) with an index child not being peanut allergic. This concludes that children are more likely to be allergic to peanut if they have a peanut allergic sibling. Allergists should consider testing younger siblings before peanut is ingested.

Management and prevention allergies and asthma

SAN DIEGO- Moldy wall surfaces contain higher numbers of house-dust mites, compared to wall surfaces without mold, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Previous research studying the distribution of house-dust mites (HDM), concluded that there are no HDM on the walls. Yael Gernez, Hopitaux de Marseille, Marseille, France, and colleagues, sought to determine if moldy dwellings may have house-dust mites (HDM) because of high humidity, favoring both mold and HDM development.

Researchers studied 50 residences with moldy wall surfaces at least equal to 50 cm². Dust was collected from both the moldy surface and 20 cm away from the mold. It was then observed for HDM.

Results showed that 54% of moldy wall surfaces contained HDM, compared to 6% of walls without mold. This shows that HDM avoidance programs should include elimination of moldy surfaces in the home.

Exposure to dogs during infancy reduces risk of asthma
Children exposed to dogs during infancy have a reduced risk of asthma at age six, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Nicholas A. Hallett, University of Wisconsin School of Medicine and Public Health, Madison, WI, and colleagues, examined the relationship between pet ownership and asthma diagnosis in 253 children enrolled in the Childhood Origins of ASThma (COAST) study. Pet ownership was categorized in groups according to exposure at birth, age three years, both or neither. All statistical analyses compared exposure groups to non-exposed children.

Results showed that children who owned a dog at both birth and age three years were less likely to develop asthma at age six (18.3% vs. 33.6%). Cat ownership at birth and/or age three was not significantly related to asthma diagnosis at age six.

This concludes that exposure to dogs, but not cats, throughout infancy and early childhood is associated with a reduced risk of asthma at age six, suggesting that early, prolonged exposure may be a critical for environmental exposures to alter the risk of asthma.

Diesel Exposure Model Reduces Allergy Risk assessment errors
University of Cincinnati (UC) environmental health experts say their research improves prior methods of classifying exposure to diesel exhaust particulates that help minimize inaccuracies and better predict a child's risk for wheezing.

Many prior air pollution studies rely heavily on what are known as proximity (distance) exposure models, which assume all subjects in a given distance from an exposure source-for example, a major interstate highway-are equally exposed.

Pat Ryan, lead author of the UC study, says that isn't necessarily true in urban environments, where infants are exposed to a large number of pollutants, and he advocates using the so-called land-use regression model.

"Unlike proximity models," says Ryan, "land use regression lets us consider more complex exposure factors-like elevation and the type or number of passing vehicles-in our initial assessment. This allows us to create 'buffers' around specific sample sites and control for factors influencing that location's overall diesel exposure levels."

Specific models are needed for evaluating exposure levels in large cities to accurately determine exposure levels and identify populations at risk for high exposure to air pollutants, Ryan says.

He will present the UC team's findings at the annual meeting of the American Academy of Allergy, Asthma and Immunology in San Diego on Feb. 26.

Ryan and his coauthors analyzed data from 622 infants enrolled in the Cincinnati Childhood Allergy and Air Pollution Study (CCAAPS) who were identified as being at greater risk for developing allergies because at least one of their parents had allergies.

Researchers found that infants who were exposed to the highest levels of elemental carbon-a marker of diesel exposure-were more than twice as likely to wheeze compared with the infants exposed to lower levels.

Research has shown that diesel exhaust particles (DEP), breathable particles able to absorb and transport proteins, aggravate rhinitis (hayfever) and asthma symptoms.

Exposure to tobacco smoke in early life decreases IgE at 18 years of age
Exposure to parental environmental tobacco smoke (ETS) in utero or through age two years is associated with lower IgE levels at age 18 years, with a greater effect in males, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Kimberley J. Woodcroft, Henry Ford Health System, Detroit, MI, and colleagues, determined parental smoking by a predelivery questionnaire, and at one and two years. ETS exposure was determined by one parent smoking at least one cigarette daily. Total IgE was measured in blood collected from subjects at age 18 years.

Researchers found that IgE levels of male teens exposed during gestation were 11.9 kU/L, compared to 35.7 in male teens not exposed. IgE levels for male teens exposed through age two were 21.1 versus 35.3 in those not exposed.

This study shows that exposure to parental cigarette smoke in utero or through age two is associated with lower IgE levels at age 18 years. Elevated IgE levels are associated with development of allergic disease.

Children are more susceptible to pollution-induced airway diseases than adults
Children who are exposed to diesel exhaust particles (DEP) have a greater inflammatory response than adults, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

David Diaz Sanchez, PhD, University of California at Los Angeles, Los Angeles, CA, and colleagues, studied 20 adults and 15 children (10-15 years of age) who underwent randomized exposure to four DEP nasal challenges at increasing amounts. Gene expression level 24 hours after exposure, and cellular inflammation was measured and results in children and adults were compared.

Results showed that cell count and inflammation positively correlated with increasing DEP challenges in both adults and children. At the highest DEP concentration, children had increased cellular inflammation, compared to adults.

This study concludes that children have a greater inflammatory response with higher DEP exposure as compared to adults. Impaired antioxidant defenses in children may lead to increased vulnerability to pollution-induced airway diseases.

Cigarette smoke may exacerbate airway inflammation in pulmonary disease
Cigarette smoke may alter the function of mast cells and eosinophils in the course of other diseases, exacerbating airway inflammation in acute and chronic pulmonary disease, according to a study presented at the 2007 AAAAI Annual Meeting in San Diego, CA.

Philippe Hasgall and Ilham Orouk, two students working under the direction of Professors Francesca Levi-Shaffer and Leah H. Bellehsen, at The Hebrew University of Jerusalem, isolated human cord blood mast cells (CBMC) and human peripheral blood eosinophils (EOS) and exposed them to varying concentrations of cigarette smoke extract and examined the results.

Results show that in vitro exposure of human CBMC and EOS to components of cigarette smoke influenced several properties: survival, activation, mediator synthesis and release. These results show that cigarette smoke may change the function of mast cells and eosinophils in the course of other diseases, exacerbating airway inflammation in acute and chronic pulmonary disease.

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These studies were presented at the 2007 Annual Meeting of the American Academy of Allergy, Asthma and Immunology (AAAAI). The AAAAI is the largest professional medical specialty organization in the United States representing allergists, asthma specialists, clinical immunologists, allied health professionals and others with special interest in the research and treatment of allergic disease.

Allergy/immunology specialists are pediatric or internal medicine physicians who have elected an additional two years of training to become specialized in the treatment of asthma, allergy and immunologic disease.

Established in 1943, the AAAAI has more than 6,000 members in the United States, Canada and 60 other countries. The AAAAI serves as an advocate for the public by providing educational information through its Web site, and its Physician Referral and Information Line at (800) 822-2762.



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