Dr. Summit Shah
The 3rd week in September marked Asthma Peak Week for 2019. What is Asthma Peak Week? It is a week when certain conditions come together to create a perfect storm for asthma sufferers. As a result, hospitalizations and private practice visits related to asthma increase that week across the country. The contributing factors include the beginning of cold and flu season, exposure to new germs due to the start of the school year, and growth in mold and ragweed. The resulting burden on asthma sufferers can exacerbate their attacks and can be particularly dangerous for elderly patients, children, and people whose immune systems are compromised.
The best lesson we have learned related to asthma peak week is that asthma sufferers should get ahead of it. Now that the Asthma and Allergy Foundation of America has identified this particular week as posing a threat to asthma sufferers each year, people can start planning for how to best avoid problematic asthma attacks in late September.
As with any time of year, avoiding asthma triggers is one critical way to prevent attacks. At a time of year when other factors can make your attacks worse, staying away from your triggers is particularly important. If you do not know what your triggers are, now is a good time to start watching for patterns in your asthma attacks to try to determine what may set them off.
For decades, the recommended course of action for patients with mild asthma has been to use a low dose steroid inhaler two times each day. However, a new study published in the highly reputable New England Journal of Medicine casts doubt on the value of this guideline, showing that many people suffering from mild asthma do not benefit anymore from this treatment approach than they would with a placebo.
The idea behind using a steroid inhaler is that the medicine in the inhaler fights inflammation by mimicking cortisol, a steroid hormone known to reduce inflammation. The problem is that most of the research that has suggested that this type of inhaler benefits asthma patients has been conducted on patients with severe asthma. According to this new research, only about 1 out of every 4 patients with mild asthma has the type of inflammation – termed Type 2 inflammation - that would likely be minimized by these steroids.
Roughly 1 in 10 people in the United States are allergic to cats. Despite exposure to cats resulting in symptoms including coughing, sneezing, wheezing, stuffy noses, and rashes in this part of our population, the desire to be around cats and to keep cats as pets does not seem to be on the decline. A Swiss company called HypoPet has therefore developed Hypocat, a vaccine to help people who are allergic to cats to live more comfortably in their company.
Interestingly, unlike most vaccines that we benefit from, for Hypocat to help us, we do not have to come into contact with the vaccine. Instead, the vaccine is administered to cats to help neutralize the problematic allergen that affects humans.
People often blame the fur on cats for their allergies, but the actual culprit is a protein - called Fel D 1 - that can be found in cats’ saliva and skin secretions. It is not wrong, however, to think of cat fur as problematic. Because cats tend to lick themselves frequently, Fel D 1 gets on their fur, making exposure to the fur potentially as threatening to cat allergy sufferers as exposure to a cat’s tongue.
Northwestern University researchers have found that sesame allergies are more common in the United States that experts previously thought. According to their analysis of data from 50,000 households and more than 80,000 people, sesame allergies affect more than 1 million people in the U.S. While approximately 1.1 million people reported a sesame allergy diagnosis, more than 1.5 million people reported that they believe they suffer from the allergy.
The results, which were recently featured in JAMA Network Open, also show that both children and adults can develop sesame allergies and that the reactions can be severe. This feature of sesame allergies distinguishes it from other common food allergies, like milk and egg, which typically begin at an early age and often decline as children age.
New research out of the Boston Children’s Hospital has demonstrated an important role of gut bacteria in food allergies. The scientists transplanted fecal material from human babies with and without food allergies into mice that had been engineered to have severe egg allergies. When mice received fecal matter from babies with food allergies, their egg allergies persisted. However, when they received fecal matter from healthy babies, they were protected from anaphylaxis - a potentially fatal allergic reaction.
Back in the 80s and 90s, researchers began observing that gut bacteria in animals appeared to play a role in preventing food allergies. Specifically, something about gut bacteria was ensuring that the immune system recognized foods as harmless, even though they were foreign. Normally, the immune system attacks foreign entities it deems harmless as a way to ensure health and safety.
In 2000, a new study was published showing that mice with a specific genetic mutation disrupted communication between gut bacteria and the immune system. What was fascinating, though, was that mice with this mutation also experienced anaphylaxis when they were exposed to peanuts.
Since this key combination of observations linking gut bacteria to food allergies, it has been shown that a causal relationship exists between the microbiome and food allergies. One specific species of bacteria, known as Anarostipes caccae, is important for preventing allergies to cow’s milk. This role of Anarostipes caccae was discovered when it was observed that mice with lower levels of this bacteria were more likely to have allergic reactions to cow’s milk and that transferring this bacteria to mice could protect against such allergic reactions.
How can this information on the connection between gut bacteria and food allergies be put to use?
Researchers have established ways to use differences in the microbiome to predict which children will outgrow their food allergies. Ongoing research into the mechanisms underlying this connection will hopefully lead to the development of strategies to prevent or treat food allergies. Clinical trials are currently underway to determine if probiotic supplements may provide an opportunity to combat food allergies.
Many asthma sufferers do not realize that there are different types of asthma diagnoses that depend on the frequency of asthma symptoms. Whereas people who suffer from asthma symptoms regularly are often diagnosed with persistent asthma, those who experience symptoms 2 days each week or less are likely to be diagnosed with intermittent asthma. Those with intermittent asthma also do not have more than 2 night flares each month.
The main feature of intermittent asthma is flare-ups occurring only a few times each month. The symptoms themselves can range in severity, but most people with intermittent asthma have mild symptoms. It is possible for those with intermittent asthma to have asthma that progresses to persistent asthma.
Whether intermittent or persistent, asthma tends to generally include the same symptoms. These symptoms include difficulty breathing, chest tightness, shortness of breath, coughing, and wheezing. Coughing tends to happen more frequently at night or following exercise. These symptoms are caused by a few different physiological activities, including inflammation in the airway and shrinking and spasms of the lungs.
Those with intermittent asthma often notice that their symptoms are triggered by specific stimuli, such as certain chemicals, smoke, pollen, cold air, or pet dander. Respiratory infections often also lead to asthma symptoms in intermittent asthma patients.
Intermittent asthma patients can manage their symptoms by avoiding their triggers, but they will often still require medical intervention as well. Treatment for intermittent asthma, however, may be different than treatment for persistent asthma. Specifically, intermittent asthma often requires fewer treatments. The treatments are likely to be short-acting beta agonists, such as albuterol - also known as a rescue inhaler - or oral corticosteroids like prednisone. Even though people with intermittent asthma may feel as though their symptoms resolve, it is important to pursue treatment to prevent severe asthma attacks.
Trying to predict whether children will develop asthma is not a new pursuit. People who have asthma themselves or who know that their children carry risk factors that may increase their children’s likelihood of getting the disease are eager to get their hands on information that can help them predict whether their children will one day have asthma. To date, most of the tools to help assess children’s risk of developing asthma have been binary, meaning that their readout simply says that a child is or is not likely to develop asthma.
A new online tool, the Pediatric Asthma Risk Score (PARS) is a free way to evaluate asthma risk in young children, and it gives a more dynamic picture of a child’s asthma risk than other tools can. PARS asks questions related to 6 known risk factors for asthma: parental asthma, race, allergy skin test results, wheezing, and difficulty breathing. The output of the tool is a percentage likelihood that the child will have asthma by the time he or she is 7 years old.
Compared to the sensitivity of the standard Asthma Predictive Index (API), that of PARS is 11% higher. Researchers hope that they will be able to incorporate more risk factors into the tool over time so that it becomes even more sensitive.
Tools like PARS can be helpful for parents not only to alleviate the worry they may feel about the potential for their child to develop asthma but also to help them to be proactive when their child is at significant risk. Those who find that their child is likely to develop asthma can learn how to best monitor their child and help to ensure that they intervene early if intervention is indeed needed.
Given that PARS is more sensitive than other tools for assessing as asthma risk in young children, it could become very useful for clinicians and parents. Other benefits of the tool are that it is free, non-invasive, and provides more information than other tools.
Even if the only time we spend at home is while sleeping, we spend a significant amount of time in our houses. For people with allergies, ridding the home of as many allergens as possible can improve quality of life and reduce allergy symptoms on a daily basis. While it may be difficult to completely remove all allergens, using certain appliances can have a large impact in decreasing the number of allergens in your home. Some of the most beneficial appliances are:
- Vacuum cleaners that have HEPA filters built into them. HEPA filters help to trap even the smallest dust particles. Using these kinds of vacuums in the house at least once a week can be incredibly helpful in getting rid of problematic allergens.
- Fresh air filters in the HVAC system. Fresh filters will trap more dust than older filters and will also keep the system operating efficiently so that air is well circulated.
- Stand-alone air purifiers. Air purifiers work by both circulating air around rooms and also trapping particles in the air. Research on the impact of air purifiers has found that when air purifiers are used properly, they can reduce particulate matter by about 50%.
- Exhaust fan over stove. Humidity in the house can lead to mold that can cause or exacerbate allergy symptoms. Using an exhaust fan over the stove - particularly when cooking with high heat - can help reduce humidity and resulting mold.
Technological innovations have been beneficial for those with allergies because they have led to the development of effective and affordable appliances that can help us combat allergy symptoms and allergic reactions. However, there are also some very simple solutions to help rid houses of allergens. For instance, replacing bedding regularly and ensuring that bedding is made of cotton rather than synthetic fibers can help to minimize allergic reactions. Switching out rugs can also get pet dander, pollen, and dust out of the house. Combining these different strategies is the best way to ensure that your house is as allergen-free as possible
Food allergies have increased over time, especially in young children, as has the consumption of highly processed foods. New research suggests that this co-occurrence may not be a coincidence. A new study has shown that food allergies in children are in fact associated with higher levels of a compound found in junk food. The compound, called advanced glycation end product (AGE), is a protein or lipid that has been exposed to sugar.
AGEs are already known to have a role in certain neurological disorders and diseases such as diabetes. They are found in processed and microwaved foods as well as in many meat products. Given the high levels of AGEs in junk food, scientists have begun to wonder if these compounds could account for the link between diet and rising food allergies.
To evaluate the relationship between AGEs and food allergies in children, researchers conducted a study comparing children who had food allergies to those with respiratory allergies and those with no allergies. There were 61 study participants, and they ranged in age from 6 to 12 years.
The scientists found that children who ate more junk food had higher levels of AGEs beneath their skin. Additionally, compared to those with respiratory allergies or no allergies at all, children with food allergies had these higher levels of subcutaneous AGE. These results suggest that the AGEs found in junk food could have something to do with the development of food allergies in children.
This new study is not the first to point to suggest that junk food could adversely impact the immune system. Another study, conducted in 2013, investigated the relationship between fast food consumption and the likelihood of developing asthma, rhinoconjunctivitis, and eczema. This study, which involved the analysis of data from nearly 320,000 adolescents and over 180,000 children found that eating fast food at least 3 times each week was associated with a significant increase in the risk of developing allergic disease.
The specific role junk food plays in allergies, asthma, and other allergic diseases is not yet clear. However, accumulating evidence suggests that these foods may be to blame not only for issues like obesity but also for the rising food allergy prevalence. Though we know that staying away from junk food is important for maintaining a healthy weight, it may be the case that avoiding these foods can also lower the risk of developing food allergies.
A new study aimed at understanding how to improve asthma control in adults over the age of 60 has found that customizing education about asthma and how to use medications significantly improves these patients’ likelihood of taking their medications. As a result of better medication adherence, these patients also experience better asthma control. Data from this randomized trial are published in JAMA Internal Medicine.
Older adults tend to suffer from worse asthma control than younger adult patients. Given that less than 40% of older asthma patients regularly use their medications, the authors of this new study hypothesized that finding ways to improve medication adherence could be the key to improving asthma control in this population.
New York City residents over the age of 59 with uncontrolled asthma participated in this trial, called the Self Management Behaviors in Older Adults (SAMBA). Each of the 406 participants was randomly assigned to receive a self-management intervention that occurred at home, a clinic-based intervention, or usual care without management support.
The researchers found that the patients who had interventions experienced better control of their asthma symptoms and better quality of life over the course of 12 months of follow-up. After a year of interventions, these patients also visited the emergency room for asthma-related issues less frequently than the control group that received no management support.
When the researchers investigated the specific medication-related behaviors, they found that those who received the interventions were more likely to take their recommended medications and correctly use their asthma inhalers than those who were not given the relevant support. Whether the interventions were provided at home or in the clinic did not affect outcomes.
These results improve our understanding of how to help older asthma patients better control their asthma symptoms, mainly by enabling them to properly follow clinicians’ medication recommendations. The results also point to the importance of customizing solutions to specific populations, which requires understanding the specific challenges that different groups of asthma patients may face.