July 2012

 

Summer Bulletin Online Now

Our Summer Bulletin is posted, so click over to read Editor Lisa Becker’s “Notes” column on what it takes to write for the Bulletin, plus great articles on smoking cessation in the mentally ill and ideas for expanding the scope of your hospital lab. READ BULLETIN  

SAFS May Explain Why Some Kids Fail Asthma Therapy

A newly described sub-phenotype of asthma known as severe asthma with fungal sensitization (SAFS) may be responsible for at least some cases in which children fail step 4 or greater therapy. New York researchers investigated SAFS in a study involving 41 children who had failed combination asthma therapy. All of the children were assessed for serum immunoglobulin E (IgE) levels and fungal sensitization patterns. Seventeen, or 41.5%, were diagnosed with SAFS. Compared to children without SAFS, these children were older, had higher serum IgE levels, and performed worse on pulmonary function tests; the differences remained significant even when children with SAFS were compared to a subset of children without SAFS who were sensitized to non-fungal environmental allergens. Aspergillus spp and Alternaria spp were the most commonly implicated organisms in SAFS, affecting 81.2% and 68.8% of the children, respectively, but numerous other species were represented as well and more than 65% of the children with SAFS exhibited sensitization to more than one fungal species. The findings suggest airway remodeling and persistent eosinophilia may also be associated with SAFS, but the investigators emphasize additional studies will be necessary to more clearly characterize these features of the disease. The study was presented at the recent American Thoracic Society (ATS) meeting. READ PRESS RELEASE

Standard Measures Don’t Measure Up

British researchers who set out to determine whether standard assessment measures can predict which asthma patients can safely step down their dose of inhaled corticosteroid treatment came up short. Their study, also presented at the ATS meeting, enrolled 200 nonsmoking adults with mild to moderate asthma who had an Asthma Questionnaire Score (AQC) of less than 1.5, had not used oral steroids in the previous three months, required oral steroids for no more than one exacerbation in the previous year, had not been hospitalized for asthma, and had a smoking history of less than 10 pack years. After being assessed with spirometry, ACQ, serum eosinophils, serum IgE, sputum induction, and methacholine challenge (PC20), the patients were placed on a 50% reduction in ICS dose. LABA medication was maintained. Spirometry and ACQ were repeated at seven days and three months and PC20 and sputum at three months. Loss of control was defined as an increase of 0.5 in ACQ score, or an increase of ICS dose back to the original level. An exacerbation was defined as a need for oral steroids. Sixty-nine percent of the patients were able to reduce their ICS dose with no loss of control by the three month follow up. Among the 55 people who lost control, 27 experienced an exacerbation. No significant differences were seen between the baseline characteristics of the subjects who remained well controlled and those who lost control. READ PRESS RELEASE

Risk Factors for Exacerbation-Prone Asthma

In a third study presented at ATS, an exacerbation-prone phenotype of severe asthma was linked to several different risk factors by Swedish researchers who followed 93 patients with severe asthma and 76 patients with mild-to-moderate asthma for one year. Over that period, the investigators noted 122 exacerbations; 104 in 52 patients with severe asthma and 18 in 16 patients with moderate asthma. Frequent exacerbations were only seen in the severe asthma group. Higher doses of inhaled and oral glucocorticosteroids, worse asthma control, and higher C-reactive protein levels and sputum eosinophils at baseline were noted in the frequent exacerbators when compared with non-frequent exacerbators. These patients also experienced a significantly faster decline in FEV1/FVC ratio. When frequent exacerbations were defined as two or more events per year, Juniper asthma control questionnaire (ACQ) score, sputum eosinophils ≥2%, smoking history, lower quality of life, and FEV1 ≤70% were associated with the development of exacerbations. When frequent exacerbations were defined as three or more events per year, body mass index >25, quality of life, smoking, and Juniper ACQ score were associated with the development of exacerbations. READ PRESS RELEASE

Mannitol Measures Up

A new study out of Scotland finds mannitol could play a role in helping to assess asthma patients receiving inhaled corticosteroids (ICS). Researchers arrived at that conclusion after analyzing screening data on mild to moderate persistent asthmatics on ICS therapy. All underwent mannitol and/or methacholine challenges. Fractional exhaled nitric oxide (FeNO), and salivary eosinophilic cationic protein (ECP) were measured during the same screen. Mannitol airway hyperresponsiveness (AHR) was grouped by the cumulative provocative dose required to produce a 10% fall in FEV1, or PD(10): mild (315–635 mg), moderate (75–315 mg), and severe (0–75 mg). FeNO groups were low (<25 ppb), medium (25-50 ppb), and high (> 50 ppb). Methacholine was grouped according to the provocative concentration of methacholine required to cause a 20% fall in FEV1, or PC(20): mild (2-8 mg/ml), moderate (0.5–2 mg/ml), and severe (0–0.5 mg/ml). Results showed:

• Mannitol PD(10) groups were significantly different overall for FeNO: 43% higher in the severe vs. the mild group.
• There was a significant overall difference for methacholine PC(20): a 2.1 doubling dilution difference between severe vs. mild mannitol groups.
• FeNO groups were significantly different overall for mannitol PD(10) and methacholine PC(20).
• Methacholine PC(20) groups were significantly different overall for mannitol PD(10) and FeNO.
• No significant differences were found across any groups for salivary ECP, FEV1% predicted, or ICS dose.
• Mannitol PD(10), methacholine PC(20), and FeNO as continuous variables all correlated with each other.

The study was published ahead of print in Lung on June 9. READ ABSTRACT