COPD & asthma linked to poor anaphylaxis outcomes

patient with maskResearchers have found that patients with chronic lung diseases, including asthma and chronic obstructive pulmonary disease (COPD), are significantly more likely to have poor outcomes when hospitalized for anaphylaxis and other allergic conditions compared with other patients.

Zuber Mulla, MSPH, PhD, Associate Professor and Director of Epidemiologic Research at the University of Texas School of Public Health and Estelle Simons, MD, FRCP from the University of Manitoba, Winnipeg, Canada identified 30,390 patients who were hospitalized in Texas for allergic conditions between 2004 and 2007. Of these, 2,410 had a primary or secondary diagnosis of anaphylaxis at discharge.

The 2,772 (9.1%) patients in the overall cohort who had asthma were 67% more likely to receive mechanical ventilation than patients without asthma, while the 1,818 (6.0%) patients with COPD were 35% more likely to be admitted to the intensive care unit (ICU), 41% more likely to experience a prolonged stay in hospital (over 3 days), and 98% more likely to receive mechanical ventilation than those without the condition.

Patient on ventilatorIn the sub-cohort of patients with anaphylaxis, patients with asthma (n=334; 13.9%) did not have an increased risk for mortality compared with other patients, but they were over two-times more likely to be mechanically ventilated than patients without asthma).

Meanwhile, COPD patients with anaphylaxis (n=149; 6.2%) were 86% more likely to experience a prolonged hospital stay and 61% more likely to receive mechanical ventilation than patients without COPD.

Other lung conditions associated with poor outcomes included pulmonary eosinophilia, which increased the odds for ICU admission in patients with allergic conditions, while chronic bronchitis, emphysema, and interstitial lung diseases were linked to an increased risk for hospital mortality.

In particular, in the sub-cohort of patients with anaphylaxis, interstitial lung disease was linked to an 8.71-fold increased odds for mortality and a 5.16-fold increased odds for mechanical ventilation.

Writing in BMJ Open, Mulla and Simons say that their “unique exploratory analysis of a large database offers new insight into the effects of chronic pulmonary disease on anaphylaxis, an area for which there has previously been a dearth of information.”

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Chicken Soup For the Airways?

As we approach Fall, our thoughts turn to pumpkins, cold mornings, dark nights and welcoming bowls of soup.  Soup is also on the minds of a group of researchers in Scotland. A new study will be conducted by Baxter Food Group, together with researchers from the University of Aberdeen plan to study whether soups enhanced with vitamin E may help reduce the chance of childhood asthma.

Together, they have developed 3 soups containing ingredients with high levels of vitamin E. By judicious tweaking of ingredients, for example, substituting normal tomatoes found in cream of tomato soup with their sun-dried counterparts, they were able to develop three new varieties of “super-soups”.  The soups also contain other ingredients rich vitamin E, including beans, lentils, wheat-germ, sunflower oil and sun-dried tomatoes.  They’ve also created “placebo soups” which have been made to look and taste similar to the real ones, but do not contain intensified levels of vitamin E.

Their intent is to increase the daily intake of vitamin E among pregnant women from current levels which are on average of 8mg per day to approximately 15mg per day.  The 50 women involved in the study will begin consuming 3 servings of soup per week when they are 12 weeks pregnant, and do the same until they deliver their babies.

They will examine whether the new dietary intervention is well tolerated by the women and if it has the desired effect on vitamin intake. And, during the first week of the babies’ lives their lung function will be examined.

The researchers hope that fortifying soup with vitamin E could help prevent childhood asthma.  Prior studies have shown that low vitamin E diets for pregnant women tend to result in babies being born with a higher chance of asthma by the time they reach 5 years old.   But this will be the first asthma study to use dietary supplementation of vitamin E rather than tablet supplements.

Graham Devereux, Professor of Respiratory Medicine at the University of Aberdeen and Honorary Consultant Physician at Aberdeen Royal Infirmary, commented: “Although far more difficult, it seems more natural to give vitamin E in a natural food form rather than a vitamin E pill because the vitamin E containing foods comprise a complex mix of nutrients that might be critically important. When one considers the foods containing vitamin E, soup seems an obvious intervention”.

The overall approach has support from both nutritionists and asthma experts.

If we’re really lucky we might show that the children [born to women] receiving vitamin E enhancement may actually have better lung function,” Prof Deveraux says. “The ultimate aim of this research is to reduce the prevalence of asthma by an effective, inexpensive, acceptable and safe public health dietary intervention. If successful, the proposed intervention could form the basis of public health dietary advice to pregnant women that could reduce the prevalence of childhood asthma by 15-20% within five years.”

Depending on the outcome of the current study, Deveraux and his team plan to launch a much bigger study.

So will these super soups work?  Stay tuned and we’ll ladle out the news as it breaks!

Peanuts and Pregnancy

As we’ve discussed before, peanut allergies are on the rise. One study showed that the incidence of peanut allergy in children doubled between 1997 and 2002. Now, it seems researchers have discovered one of the reasons why.

A study of almost 62,000 mothers showed that the children of those who ate peanuts and tree nuts while pregnant were less likely to develop asthma or allergies than the kids whose mothers shunned nuts.

The results support the recent withdrawal of recommendations in both the US and the UK that pregnant women should avoid nuts because they might raise a child’s risk for allergies to the nuts.

There is little research on peanut eating during pregnancy and the subsequent risk for peanut allergy in her children yet the fear continues to lead many expectant mothers to steer clear of nuts.

So, researchers at the Centre for Fetal Programming at Statens Serum Institut in Copenhagen, wanted to take a more extensive look at nut exposure and the possible health outcomes in kids.

The mothers provided information about how often they ate peanuts and tree nuts, such as almonds and walnuts, during pregnancy.

At age 18 months, the researchers found, the kids whose mothers ate peanuts were less likely to have asthma.

Fifteen percent of kids whose moms ate peanuts more than once a week, had asthma compared to more than 17 percent of kids whose moms never ate peanuts.

When other asthma risk factors were taken into account, the researchers concluded that kids whose mothers ate peanuts regularly were 21% less likely to develop asthma.

At seven years old, this same group of kids was 34% less likely to have a diagnosis of asthma than kids whose moms had abstained from peanuts.

Similarly, mothers who ate tree nuts more than once a week had 18-month-olds who were 25% less likely to have asthma than the moms who avoided the nuts, although this difference appeared to fade as the kids reached seven years old.

Peanuts appeared to have no effect on whether kids developed nasal allergies, and the children of moms who frequently ate tree nuts were 20% less likely to have allergies.

Lead author, Ekaterina Maslova said the findings are further reassurance that moms-to-be don’t need to avoid peanuts and tree nuts, although the study doesn’t prove that nuts are actually protective against asthma and allergies.

Mahr, who is also chair of the section on allergy and immunology at the American Academy of Pediatrics, noted that interviewing people about what they eat can introduce some accuracy issues, but the findings are still interesting.

SRxA Advisor Todd Mahr, a pediatric allergist at Gundersen Lutheran Medical Center in La Crosse, Wisconsin, who was not involved in the study said “A take home from this would be if there’s no food allergy in your family, but there’s an asthma history in your family, maybe you might not want to avoid peanuts specifically.”

All of which is good news for moms with peanut butter cravings.

i-Nhaler i-Mprovement?

Asthma is one of the world’s most common chronic diseases, affecting some 300 million people and almost 5 percent of the world’s population. It’s also the 5th most costly condition in the US  - an estimated at $56 billion annually. But as we’ve reported here previously, a significant number of people with asthma either don’t use their asthma medications or use them incorrectly.

Improving asthma control is known to reduce the cost of treating asthma by eliminating unnecessary hospitalizations, ED visits, and office visits. The additional cost of an uncontrolled asthma patient compared to a controlled asthma patient is estimated at $3,000-$4,000  per patient annually.

So, we were interested to learn last week that the FDA approved a sensorized asthma inhaler that can track usage and transmit the data to a smartphone and the web. The manufacturer – Asthmapolis will begin to market the asthma sensor and both English and Spanish language versions of the companion software in the US very soon.

Our mission is to make it easier for patients and their physicians to do a better job of managing asthma with less effort than traditionally required.” said David Van Sickle, co-founder and CEO of Asthmapolis.

The small and lightweight device attaches to the end of most inhalers, and the app tracks the time and location of each medication discharge and reminds patients to use it if they forget.

In clinical studies of the Asthmapolis system, uncontrolled asthma declined by 50%, and more than 70% of patients improved their level of control.  In addition it can identify trends in a patients asthma triggers and symptoms over time and provide patients with personalized education on how to improve their asthma.

Not only will the device talk directly to the patients, physicians and other health care providers will be able to identify, in near-real-time, patients with uncontrolled disease and attend to them before they suffer a severe exacerbation.

Despite all we know about asthma and how to treat it, the majority of patients still do not have the disease under control, and traditional approaches to self-management have been time-consuming and complicated,” said Inger Couture, chief regulatory officer of Asthmapolis. “The Asthmapolis technology makes it much easier to track symptoms and use of metered dose inhalers, allowing patients, their families and their doctors to gain a valuable new perspective on the disease.”

And that can only be a good thing.

Bring on the Bugs?

Think that keeping your children’s hands and mouths clean is helping them stay healthy?  Think again!  New research from Johns Hopkins Children’s Center reveals that exposure to common antibacterials found in soap, toothpaste, mouthwash and other personal-care products may make children more prone to a wide range of food and environmental allergies.

Using existing data from a national health survey of 860 children aged 6-18, the researchers examined the relationship between the children’s urinary levels of antibacterials and preservatives found in many personal-hygiene products and the presence of IgE antibodies in the child’s blood. IgE are markedly elevated in people with allergies.

We saw a link between level of exposure, measured by the amount of antimicrobial agents in the urine, and allergy risk, indicated by circulating antibodies to specific allergens,” said lead investigator Jessica Savage, M.D., M.H.S., an allergy and immunology fellow at Hopkins.

While antibacterials and preservatives themselves don’t cause allergies, that these agents appear to play a role in immune system development.

The link between allergy risk and antimicrobial exposure suggests that these agents may disrupt the delicate balance between beneficial and bad bacteria in the body and lead to immune system dysregulation, which in turn raises the risk of allergies,” Savage added.

In the study, those with the highest urine levels of triclosan – an antibacterial agent used in soaps, mouthwash and toothpaste – had the highest levels of IgE antibodies and their risk for food allergy risk was twice that of children with the lowest triclosan levels. Similarly, children with the highest urinary levels of parabens – preservatives with antimicrobial properties used in cosmetics, food and medications – were more likely to have detectable levels of IgE antibodies and twice the risk of environmental allergens such as pollen and pet dander.

These findings are consistent with the so-called hygiene hypothesis, which has recently gained traction as one possible explanation behind the growing rates of food and environmental allergies in the developed world. The hypothesis suggests that early childhood exposure to common pathogens is essential in building healthy immune responses. Lack of such exposure, can lead to an overactive immune system that misfires against harmless substances such as food proteins, pollen or pet dander.

Just  this week, other new research from the University of California, San Francisco has provided some answers to why children who grow up in homes with pets are less likely to develop allergies.

All of which suggests that parents should put away the hand sanitizer and let their kids play in the dirt with a dog!

What Not to Do With Your Asthma Inhaler

As most people know, inhalers are an important part of most successful asthma management programs. Considering how many people use them and how critical they are to managing asthma and preventing asthma attacks, the number of patients who make mistakes with their inhalers is shocking.

In a recent survey of 1,000 people with asthma, about half of the respondents weren’t even using controller medications, such as asthma inhalers. And, among the half who did use inhalers, an overwhelming amount – 86%, had trouble controlling their asthma symptoms.  This seems to suggest that most asthmatics simply aren’t using their inhalers correctly.

Though alarming, the statistics aren’t necessarily surprising. According to Summit Shah MD, an allergist at Nationwide Children’s Hospital in Columbus, Ohio, “It is actually very difficult to use an inhaler properly.”

As we’ve blogged about before, improper technique tops the list.

Overuse of inhalers is a close second.  When using a rescue inhaler, one to four puffs should be sufficient. More than that and the patient should consult his health care provider, who may need to adjust the medication or treatment plan.

Similarly, the frequency of rescue inhaler use should be monitored. Rescue inhalers are intended for occasional use to stave off acute asthma attacks. Using a rescue inhaler more than two days a week suggests that the patient also needs to be on a prophylactic (maintenance or controller) inhaler.

Although all patients are encouraged to talk to their own provider, SRxA’s Word on Health is  pleased to provide a number of simple asthma inhaler tips to help people use them correctly:

  • Sit upright
  • Shake the inhaler
  • Exhale completely
  • Use an inhaler with a spacer [device]
  • If you’re using a spacer device, spray the medicine into the spacer and then take in a slow, deep breath through the spacer while creating a tight seal around the mouth of the spacer with your lips
  • After breathing in the medication, hold your breath for 10 seconds
  • Repeat after one minute

Other asthma inhaler tips really come down to common sense, such as keeping inhalers in a safe place away from pets and children and where it won’t get damaged.

Here’s to better puffing!

Wheezing: Whining or Winning?

Many people with asthma avoid exercise because they’re afraid it could trigger symptoms such as shortness of breath, wheezing or a full-blown asthma attack.

However, a new report from The Cochrane Library turns these fears on their head. The authors conclude that not only is it safe for people with asthma to exercise, but it could also reduce their risk of asthma symptoms or attacks!

Study author, Kristin Carson, from The Queen Elizabeth Hospital, Clinical Practice Unit, Adelaide, Australia explains that over time patients with asthma who avoid exercise can become out of shape, losing muscle mass and cardiovascular fitness. That makes any future attempts at physical activity significantly harder, increasing the chances that patients will become fatigued and breathless and further discouraging physical activity. “This results in a spiraling cycle,” she says, in which patients are even more likely to avoid exercise.

To determine whether exercise was a danger to asthmatics, Carson and her colleagues reviewed previous studies that looked at the effects of physical training on people with asthma comparing patients who received no or minimal physical activity to those who exercised for at least 20 minutes, twice a week, over the course of four weeks.

The researchers found that the patients who had exercised, using physical training such as running outdoors or on a treadmill, cycling, swimming or circuit training were no more likely to have a serious asthma-related problem than those who weren’t exercising or who did light exercising such as yoga.

The patients who exercised also improved their cardiovascular fitness, which in turn can reduce asthma symptoms over time. There was also some evidence to suggest that exercise improved patients’ quality of life.

We found no reason for people with stable asthma to refrain from regular exercise,” Carson said. “Physicians should encourage their patents with stable asthma to engage in physical training programs.”

Even though this research suggests that exercise is safe for asthmatics, we suspect that many people will still think they can use their asthma as a reason to avoid physical activity.

Well now there is no excuse, and just in case you’re in any doubt consider the following list of people who never let asthma stop them:

Do you have any asthma and exercise stories to share?

There’s a Shot for That

On May 14, 1796 Edward Jenner injected fluid from the cowpox blisters on the hands of dairymaid Sarah Nelmes, into James Phipps, an 8-year-old boy.  Jenner hoped the fluid from the cowpox lesion would somehow inoculate the boy against the smallpox scourge which at the time was killing over 400,000 Europeans a year. His hunch proved correct.

Today vaccines save 3 million lives per year worldwide. By training the human immune system to recognize and ward off dangerous pathogens, vaccines can protect against disease for decades, or even for a lifetime. Preventive vaccines work by introducing harmless microbial chemical markers, known as antigens, which resemble the markers on living microbes. The antigens train the immune system to recognize and destroy those microbes should they ever appear in the body. By injecting cowpox antigens into Phipps bloodstream, Jenner primed his immune system to attack the similar smallpox virus.

Now, medical scientists are taking Jenner’s ideas in a whole new direction. By exploiting a growing understanding of the immune system they are developing therapeutic vaccines targeting established diseases rather than trying to prevent them.

Last spring, the FDA approved Provenge, a personalized immunotherapy that activates a patient’s own immune cells to target and attack advanced prostate cancer. To make the Provenge prostate cancer vaccine, biochemists at Seattle’s Dendreon Corporation extract a sample of a patient’s own immune cells and bathe them in a chemical soup of prostate cancer antigens that are chemically linked to a cytokine that screams, “Attack this!”.  The activated immune cells are then injected back into the patient’s body to spread the call to arms.

While Provenge was the first of the new generation of therapeutic vaccines, it’s certainly not the last. BCC Research has identified 113 therapeutic vaccines in development, many of which are already in human trials. They even go so far as to estimate that the market for therapeutic vaccines will have an annual growth rate of 115% and reach an estimated $2.9 billion in 2014.

Other cancer vaccines are among the front runners. With a near-endless supply of patients willing to undergo novel treatments, cancer researchers have been among the most aggressive in experimenting with therapeutic vaccination. The Cancer Vaccine Collaborative is working on treatments that target multiple cancer antigens, which should trigger a more aggressive immune response and increase the odds of defeating tumors. All of which is good news for the 1.5 million Americans diagnosed with cancer each year.

While cancers cause a proliferation of diseased cells, some autoimmune diseases, cause the cells of the immune system to turn against healthy tissues. In diabetes, for example, the immune system attacks insulin-making pancreatic beta cells.

In multiple sclerosis, it’s the myelin sheaths that are designed to protect the nerves that come under attack.

Autoimmune vaccines hold the promise of shutting down these attacks. One promising approach boosts T-regulatory cells, a subgroup of the white blood cells. At the University of Calgary’s Diabetes Research Centre in Alberta, immunologist Pere Santamaria has attached a cocktail of antigens from pancreatic beta cells to synthetic iron oxide nanoparticles. This stimulates the development of T-regulatory cells into killer T cells that destroy the immune cells which cause the serial killer like autoimmune attack.

Santamaria’s team recently tested his vaccine in diabetes-prone mice. It restored normal blood sugar and insulin levels in animals that already had diabetes and prevented or slowed its onset in young mice that had not yet developed the disease. The team is now readying the vaccine for human trials and is designing related vaccines to treat other autoimmune diseases, including multiple sclerosis, rheumatoid arthritis, and inflammatory bowel disease.

If effective, such therapeutic vaccines could help the three million Americans with type 1 diabetes and the 400,000 people diagnosed with multiple sclerosis. Vaccines against dust mites and asthma are also in the works.

Some of the new therapeutic vaccines are actually designed to attack the body, albeit in a selective way. A new experimental heart-disease vaccine takes aim at unwanted biochemicals within the body, specifically low-density lipoprotein (LDL), better known as bad cholesterol. When large quantities of LDL cholesterol circulate through the bloodstream, it can be deposited on artery walls, leading to a buildup of plaque and triggering inflammation. Anti-cholesterol vaccines encourage the immune system to attack LDL and remove plaques. Scientists have also discovered that the vaccine lowers blood pressure and protects against the rupture of aneurysms, at least in mice.

Clinical trials in humans are expected to start later this year and if successful could help to prevent the 800,000+ deaths per year from cardiovascular disease.

Even more people could be helped by an anti-obesity vaccine. Nearly 75 million adults are classified as obese in the United States. Researchers are working on a vaccine that targets ghrelin – a gastrointestinal hormone that appears to stimulate appetite.

Others, are looking at vaccines to prevent addiction to cocaine, methamphetamines, opiates and nicotine.

It is too soon to know how and when these vaccines will come to market or how effective they will be, but it’s clear that therapeutic vaccines are coming and will be used against a host of the most prevailing public health issues of the 21st century.

Improving Inhaler Instruction

Many of us have never been properly trained on how to do or use certain things we really should be good at. Putting on condoms and wearing seat belts are just two that come to mind.  And when we get them wrong, the health consequences can be serious.

The same goes for asthma inhaler use.  Do you shake the device first? Did you breathe in with sufficient force? Did you press the canister at the right time?

Improper use of inhalers is a serious and expensive problem. In the US, 3 patients are admitted to the emergency room with asthma every minute, that’s >5,000 people a day!  Worse still, according to the Asthma and Allergy Foundation of America, 11 people die from asthma every day.

One study estimated up to 94% of patients use their inhalers incorrectly.  The most common mistakes include failure to exhale before actuation, failure to breath-hold after inhalation, incorrect positioning of the inhaler, incorrect rotation sequence, and failure to execute a forceful and deep inhalation. Those of us in healthcare have even seen patients who fail to take the cap off the inhaler before use, and others who use it nasally rather than orally.

This is hardly surprising given that many patients never receive instructions on how to use their inhalers and even those that do, are not routinely followed.  And let’s face it, some of these devices could use training wheels.

Enter the T-Haler, a digital asthma inhaler training device  developed by researchers at Cambridge Consultants.

Patients with asthma can use the inhaler and, via interactive software linked to the wireless device, get real-time visual feedback on the areas that need improving.

Specifically, whether patients have shaken the device before breathing in; whether they use sufficient force when breathing in; and whether they press down the canister that releases the drug at the optimal time. Click here to see a video of the T-haler in action.

Although still a conceptual product, the company says it has been designed as a training device to be available at pharmacies, schools, and clinics for children and adults alike.

They performed a study on 50 people aged 18 – 60 who had no prior experience with either asthma or inhalers and were given no instruction on how to use an inhaler. When tested, about 80% of the participants used an inhaler incorrectly.

They were then given the T-Haler with no further instruction and told to begin. A three-minute on-screen tutorial guided them through the proper use of an inhaler, and the success rate tripled to more than 60%.

Without any human direction beyond the word ‘go’, participants went from around a 20% success rate without training to a success rate of more than 60% after only three minutes with the T-Haler device,” said Kate Farrell, a senior design engineer, in a news release. “This is more than twice the compliance rate we have seen in other studies with trained participants. Interestingly, a week later, 55 percent were still correctly using the device-showing that they retained what they learned.”

Whether the T-Haler itself will ever make it to market remains to be seen, but the concept of a 3-minute training device seems a no-brainer when it comes to properly using a device that may very well save the lives of the estimated 235 million asthma sufferers worldwide.

Shocking Study shows the US is slipping in asthma control

Asthma is a common illness, affecting over 300 million people worldwide. In the US approximately 10% of children and 8% of US adults have the disease. Despite the fact that it is treatable, approximately 180,000 people die as a result of asthma each year, 4,000 of them in America.

Maybe now we know why.  According to results of a first of its kind survey, 49% of children and adults with persistent asthma are not using controller medications.

The results of the 1,000 asthma sufferer CHOICE (Comprehensive Survey of Healthcare Professionals and Asthma Patients Offering Insight on Current Treatment Gaps and Emerging Device Options) survey were published in the March 2012 issue of Annals of Allergy, Asthma & Immunology.

Results demonstrate the current extent of poor asthma control in the US, and shows the country has fallen far short of national asthma management targets.

Among the most shocking results:

  • 79% of patients had persistent asthma and should have been on controllers.
  • Of the 51% on controllers, 86% were inadequately treated i.e., their asthma was not well or very poorly controlled.

Patients with severe persistent and uncontrolled asthma frequently reported feeling isolated, fearful, depressed and tired.

Uncontrolled asthma is severely affecting patients’ quality of life and increases the risk of emergency department visits and hospitalizations,” said co-author and SRxA Advisor Michael Blaiss, MD. “Asthma sufferers need to schedule regular office visits, talk with their allergists about preventative controller therapy and then use those medications regularly.”

Research shows that asthma patients under the care of an allergist have better outcomes at less cost because of fewer emergency care visits, fewer hospitalizations, reduced lengths of hospital stays, fewer days missed from work or school, increased productivity in their work and personal lives, greater satisfaction with their care and an improved quality of life.

So if you have asthma, suspect you have asthma or know someone with asthma, please get it treated. Most asthma deaths are largely preventable. Together we can help to change the awful results seen in this study.