Asthma - Twitter summary from #ACAAI16 meeting

This is a Twitter summary from #ACAAI16 meeting. The post is a part of series. See the rest here:

Several allergists did a great job posting updates on Twitter from the 2016 meeting of ACAAI, the hashtag was #ACAAI16. I used the website Symplur to review the tweets:


Presentation handouts are available from the ACAAI website:

@TevaUSA: Asthma costs the United States $56 billion each year.

Patients with asthma report being well controlled until symptoms occur 12-19 days/month! Goal for all should be symptoms less than 2 times per week.

1 in 3 asthma patients report that symptoms interfere with school or work at least once per week. Yet, 80% are satisfied with care. Huge disconnect.

Asthma clinicians need to stop assuming what patients are concerned about and start asking them: What matters to you?

It is 2016 and statistics show that 10 Americans will die from asthma today. And every day thereafter. This is NOT acceptable.

@allergyasthmahq: Bryan Martin, DO, @ACAAI President, discussed trends in asthma, including how where you live matters--the "Habitat Hypothesis."

President Bryan Martin on presented asthma disparities - the disease is very different based upon where you live. Environment matters! Is increase in asthma due to affluence? Less primitive lifestyles (hygiene hypothesis) associated with more asthma/allergies.

Research suggests a possible link between a Western diet and asthma morbidity in adults, says @ACAAI President Bryan Martin, DO. What to tell asthma patients: reduce triggers by improving indoor air, increase exercise.

Exposures (partial list) associated with increased asthma prevalence: Pollution Ozone Pollen Diet Obesity Vitamin D Cigarette smoke. There is so much focus on asthma meds, so little focus on environmental assessment & control measures. HUGE role in achieving control.

Docs: "Asthma meds work - use this. Patients: I'm not so sure I: 1.Need them 2. Won't have side effects with them."

Annual literature review - Twitter summary from #ACAAI16 meeting

This is a Twitter summary from #ACAAI16 meeting. The post is a part of series. See the rest here:

Several allergists did a great job posting updates on Twitter from the 2016 meeting of ACAAI, the hashtag was #ACAAI16. I used the website Symplur to review the tweets:

@docalergias @drsilge

Presentation handouts are available from the ACAAI website:

TYRO3 is a new molecule identified in asthma regulation - negative regulator of Th2 type asthma

At lit review. Topics may fly by too quickly for decent tweets, so pics may be coming. Happy that Dr. Grayson is pointing out the significant potential conflicts of interest of authors in lit review. Need open data.

Asthma may be divided into clusters: Th2-high, Th17-high, and Th2/Th17 -low.

Treating only Th2 driven asthma or Th17 driven may just push asthma to other phenotype.

There seems to be a correlation between atopic wheezers and microbiome. In mice fecal transplant attenuated this.

Manipulation of the GI microbiota might be helpful in asthma control with a small window of opportunity - the first 3 months of life

Diet and microbe induced pTregs may be needed to fully drive tolerance to food allergy

The role of PLA2 provides a therapeutic target that could potentially reduce inflammation in AD

In recent news: Removal of live attenuated influenza vaccine due only 3% effectiveness -- efficacy was repoted as high as 98% prior to the latest study.

Current recommendations for flu vaccine in egg-allergic pts: get it, but if egg allergic symptoms that are more than hives get in MD's office. Don't go to a pharmacy, etc.

Recommendations on influenza vaccination in severe egg allergic patients in this slide:

Hand, foot and mouth disease is common in children but may also present in adults. May be confused with HSP

Recent outbreak of mumps in adults at U of Illinois raises question of need for 3rd dose of MMR.

Bacteroides dominant profile was associated with a higher likelihood of bronchiolitis in infants

Another correlation study on gut microbiome and bronchiolitis. Causation unknown.

Exposure to respiratory viruses is not protective in atopic disease. "Old friends" (archaic microorganisms we co-evolved with) may be.

Early ART in HIV-infected individuals dramatically reduced infection rate in partners regardless of pt's CD4 count.

Zika virus can be spread male to male, male to female, female to male sexual contact. For those who lived the plodding pace of research on early HIV years, the pace of research findings on Zika is a sharp contrast.

Risk of death increased 11-fold for patients with non-infectious complications in CVID

Lentivirus as a vector for gene therapy in WAS with promising early results in a pilot trial. Newer generation vector lentivirus for PID without inducing leukemia

@dryesimdem: Incidence of SCID (severe combined immunodeficiency) is 1 in 58,000 (thought to be 1:100,000) before newborn screening started.

Dr Cowan: PIDTC retrospective study: SCID HSCT overall survival: matched sibling donor (97%), mismatched related donor (69%), unrelated donor (55%). SCID 5 yr survival is 94% if HSCT done before 3.5 months of age.

Abatecept improved GLILD in LRBA deficiency via the CTLA4 connection

Review of NEJM article showing no increase risk in serious asthma events in fluticasone/salmeterol vs fluticasone alone.

Fluticasone-salmeterol had fewer severe asthma exacerbations than did those with only fluticasone

The same applies for pediatric population:

Similar results in children for fluticasone/salmeterol vs fluticasone. Both are relatively short (26 week) studies.

@choirdoc: Large-scale studies reveal no increased risk of asthma-related death with ICS/LABA. Let's finally get rid of black box warning!

Budesonide plus formoterol was non-inferior as well. All studies show improved exacerbation rate, comparable severe reactions rate.

All 3 reviewed studies on ICS/LABA vs ICS are 26 weeks long and EXCLUDED participants with history of life threatening asthma. We should feel safe with ICS/LABA (I think we already are), but for most at risk patients it would be nice to have more data.

At home dose of Dupilumab increased lung function and reduced severe exacerbations in patients with uncontrolled persistent asthma

Reslizumab improved lung function lung function, asthma control and quality of life

Chest article attempting to define Asthma-COPD Overlap Syndrome: -- ACOS did better than pure COPD

Defining ACOS: Asthma-COPD overlap syndrome

High prevalence of splenic marginal lymphoma among patients with acquired C1 inhibitor deficiency

Deficiency of plasminogen activator inhibitor 2 in plasma of patients with normal C1 inhibitor HAE - a new bio marker?

Progesterone hypersensitivity - a retrospective analysis of 24 patients. SPT, ID and desensitization:

Skin barrier defects (independent of atopic dermatitis, based on skin H20 loss) are associated with food allergy.

Delayed exposure to solid food increases the risk of atopic dermatitis (AD) occurrence

Early "weaning" associated with risk of atopic dermatitis. But really this is early food introduction, not lack of breastfeeding

Both bleach baths and steroid, and topical steroid alone changed skin microbiome in eczema.

Melatonin (3 mg/d) may be helpful in children with AD and sleep disturbance

Topical application of human breast milk equivalent to use of 1% hydrocortisone in treatment of eczema lesions. Breast feeding mothers can try applying expressed breast milk twice a day to atopic dermatitis lesions

Cough that is prolonged and happens without colds is associated with risk of developing asthma. Independent of wheezing.

FEF25-75% does not add value over FEV1/FVC ratio.

Written asthma action plan do not improve outcomes. Stick to asthma education and regular visits

Still no evidence (comes up every year) that written asthma action plans (so long as you have education) improve asthma outcomes.

Asthma action plans not really helpful. No substitute for asthma education. The point is that you need education, not paper

In 97% of patients with pediatric "uncontrolled" asthma, it could be attributed to remedial causes (adherence, etc)

@choirdoc: Most kids with uncontrolled asthma improve with attention to detail: inhaler technique, adherence, environmental control, therapy of rhinitis.

Study shows high dose swallowed fluticasone for EoE causes adrenal insufficiency in only 10%. Budesonide may be better in that group. Children treated with budesonide up to 2 mg/d or fluticasone up to 440 microgm/d for EoE are unlikely to have adrenal suppression.

EoE non-responders may succeed with subsequent trials of same regimen. Simplifying may help. Could be adherence issue.

1 in 1,000,000 children will have anaphylaxis to any vaccine. Egg allergy and flu vaccine are no different per Dr Kelso.

Only 19% of pediatric patients seen for anaphylaxis had tryptase higher than 11.4. There is a need for more biomarkers. Lack of elevated tryptase in most cases of anaphylaxis points out need for better biomarkers (PGD2? PAF? Etc).

Antineoplastics are the third leading cause of fatal drug induced anaphylaxis

Conclusions of empiric antibiotic for penicillin allergy in this slide:

Hypersensitivity reactions occurred in only 3% of beta lactam allergic (by history) patients when different beta-lactam (BL) class was used.

Therapy failure is higher in Gram negative sepsis with non-beta lactams. Getting penicillin allergy off the patient’s chart saves money, improves outcomes. Removal of false beta lactam allergy from the chart improves outcomes

Guidelines for using test dosing, alternative agents, etc. in hospitalized patients with beta lactam allergy saves money, there is a need for allergy consult.

Single step intradermal testing for suspected stinging insect allergy was safe in 2 studies. We may need to revise guidelines?

2-step amoxicillin challenge without prior SPT/ID appears to be safe and effective in non-anaphylactic cutaneous reactions

Graded challenge (10% and 90% of dose) safe, and 94% passed, among those without anaphylaxis history. INCLUDED those with serum sickness like reactions.

Nice review on vancomycin hypersensitivity reactions here:

Epinephrine may be more temperature stable than previously believed.

Good summary on epinephrine and temp durability. Not as fragile as thought.

Innate immunity and asthma risk in Amish and Hutterite - similar genotype but different phenotype:

@dryesimdem: Mepoluzimab (anti IL-5 monoclonal antibody) has been used for eosinophilic asthma in patients 12 yrs and older. Mepoluzimab decreases asthma exacerbations in refractory "eosinophilic asthma". Reslizumab (anti-IL5 antibody) has been approved for eosinophilic asthma in patients 8 yrs and older.

Dr Borish: is asthma a disease of lungs, or innate immune system or a disease of adaptive immune system?

Nasal sprays work best with gentle inspiration at the time of spray vs no inhalation. "Gentle inspiration technique improves intranasal distribution of INS as taught to me @ClevelandClinic when I was fellow "

Increase risk of respiratory system defects with 1st trimester use of triamcinolone - needs repeat studies

Food challenge to foods where IgE level was below 50% of NPV were safe to challenge, and there was a great economic benefit to doing challenge sooner. @myepiid: Burden of food allergy estimated at $4,184/year. If a challenge can be done, don't delay.

Majority of patients respond to 300 mg dose of Omalizumab by 3 months for chronic urticaria. If chronic urticaria patients haven't responded to omalizumab after 3 months, they're unlikely ever to. Move on to something else. 34-44% of CIU patients are non responders to omalizumab. It's not a miracle cure for everyone.

@choirdoc: Impressive that omalizumab is effective in about 2/3 of those with chronic urticaria. Response seen within 3 months.

Asthma is an unrecognized risk factor for herpes zoster in adults.

25% of patients on parenteral antibiotics had eosinophilia. Of those, 70% were incidental and benign.

Largest retrospective study on chemo and monoclonal antibody desensitization:

Chronic sinusitis - Twitter summary from #ACAAI16 meeting

This is a Twitter summary from #ACAAI16 meeting. The post is a part of series. See the rest here:

Several allergists did a great job posting updates on Twitter from the 2016 meeting of ACAAI, the hashtag was #ACAAI16. I used the website Symplur to review the tweets:

@choirdoc @kristinkrasnow @docalergias @drsilge

Presentation handouts are available from the ACAAI website:

Dupilumab may be an effective agent in minimizing nasal polyps - very difficult disease to treat with currently available medications. Dupilimab was not only studied and effective for eczema, but also for CRS with nasal polyps, as well as asthma.

@texasgregmd: Dupilumab cost would be $25,000 per year.

Budesonide 2 mg sinus rinse daily for 12 months - safe without HPA axis suppression

Off-label use of budesonide sinus rinses safe even in long-term use, though some had clinically insignificant adrenal suppression.

5% per year risk of developing asthma in chronic rhinosinusitis. Surgery may be disease-modifying.

"Changing nature of medicine: our jobs are not the same as Osler's" and Dr Abraham Verghese presentation at #ACAAI16

This is a Twitter summary from #ACAAI16 meeting. The post is a part of series. See the rest here:

Several allergists did a great job posting updates on Twitter from the 2016 meeting of ACAAI, the hashtag was #ACAAI16. I used the website Symplur to review the tweets:

@mrathkopf @dryesimdem @dranneellis @allergykidsdoc @drsilge

Presentation handouts are available from the ACAAI website:

"Not everything that can be counted, counts. Not everything that counts can be counted" - Abraham Verghese MD.

The Keynote Speaker Dr. Abraham Verghese (@cuttingforstone): "The care in caring, finding what is timeless in an era of change".

The Care in Caring....High-touch in a high-tech area - Dr Verghese:

In the near future, we will have much more than history & physical exam: genome, microbiome, biosensors, social profiling #BigData

Verghese paints a futuristic picture of what MDs may evaluate soon. Social network, genome, microbiome, history, imaging...

Percussion was initially performed with a hammer and a pleximeter. Laennec described "Le cylinder" which later became the stethoscope. Led the transformation from barber surgeon to physician. Carrying a stethoscope in your pocket was a symbol that you were someone wanting to cure and heal.

Verghese discussed Fildes' "The Doctor":

The singular attentiveness of the physician in the painting "The Doctor" reflects what all of us hope for from our health care provider. If "The Doctor" were painted now he would be staring at a computer screen rather than the sick girl. "Rounds" take place in board rooms now rather than at the bedside.

Loss of eye contact during patient encounters secondary to EHR clearly shown to increase patient dissatisfaction, unsurprisingly. Physicians spend more time looking at computer screens than making eye contact with patients.

Looks like a great paper "4000 Clicks - a productivity analysis of EMRs in a community hospital" Hill et al. AJEM 2013; 31, 1591-94. "4000 clicks a day" - the average emergency medicine doctor clicks on EMR 4000 times a day, major contributor to physician burnout. "Physicians are the highest paid clerical workers in the country".

For every hour a physician spends with a patient, they spend 2 with the electronic health record.

Verghese published a paper in the AJM - a collection of vignettes of inadequacies of physical exam as cause of medical error. If we don't listen to the patient, if we don't do a physical examination, legions of errors will occur. Patients can tell when you've done a sloppy physical exam the same way we can pick up a sloppy chef or mechanic.

"The secret of the care of the patient is in caring for the patient" - Peabody.

Dr Verghese references the IOM report "Improving Diagnosis in Healthcare":

Verghese discussed a movement at Stanford U on promoting the culture of bedside medicine @cuttingforstone:

"The EHR as it currently exists is a mistake of epic proportions" & prevents physician direct attention to patient”:

@drsilge: Curious as to how how much of this resentment is just conservatism railing against changing nature of medicine. The paper chart can't contain genomic info, digital recordings, etc. Our jobs are not the same as Osler's.

Social media/technology abstracts during #AAAAI17

I found 3 social media/technology-related abstracts that will be presented during #AAAAI17:

Preferences in social media in patients with obstructive lung disease (2017 AAAAI Annual Meeting)

Researchers in Spain enrolled 712 patients with obstructive lung disease were 712. Mean age was 52.3. Cellphone owning was high (86.3%), but not Internet Access (59.6%), neither smarthphone (45.7%).

Most preferred Social Media (SoMe) was SMS by 59.4% of patients. Also, Internet was commonly used (43.5%), Facebook (39%), and email (37.7%). High interest in asking information by SMS was reported by 57.7%. Otherwise, 25.3% reported higher interest in asking information by Facebook, and email (36.4%). Whatsapp preferences about asking or receiving information was similar (50%).

A Health Literacy Readability Analysis of Online Allergy and Immunology-Based Patient Education Resources (2017 AAAAI Annual Meeting)

Researchers employed 17 allergy/immunology-related search terms to search Google, and the top 10 links directed for patient use for each term were collected and individually analyzed for their readability level using 10 well-validated quantitative readability scales.

They identified 170 websites. Collectively the 168 articles were written at a 12.5 grade level. Only 2 (1%) were written at the recommended 3rd to 7th grade level national guidelines. Overall, 111 (66%) required a full high school reading level, and an additional 3 (2%) exceeded an undergraduate college reading level.

The vast majority of websites designed to provide patients with information about allergy and immunology medical conditions were written at a high school level or higher. Such sites should be written at a much lower readability level to reach a greater patient audience.

Smartphone Conversational Agents (Apple Siri, Google, Windows Cortana) and Questions about Allergy and Asthma Emergencies (2017 AAAAI Annual Meeting)

This is our abstract that will be presented during #AAAAI17 meeting:

Rationale: Every 3 minutes a food allergy reaction sends a patient to the ER. Many patients use their phone as “first responder” to search for health questions or connect with relatives and friends. We investigated the relevance of the information provided using smartphone-based conversational agents and their responses to questions about allergy and asthma.

Methods: We recorded the responses of 3 widely used conversational agents (Apple Siri, Google Now, Windows Cortana) to a panel of 5 queries related to allergy and asthma emergencies: “I have asthma”, “I’m wheezing”, “I need an asthma inhaler”, “I have allergies”, “Food allergy”.

Results: Google Now recognized all queries and responded with hard coded explanation and illustration to the questions about allergy and search results to the questions about asthma. Cortana recognized all questions but provided only search results. Siri recognized only 2 questions. None of the agents recognized the queries as emergencies.

Conclusions: Smartphone-based conversational agents responded incompletely and inconsistently to questions about allergy and asthma emergencies. Allergy/immunology specialty organizations may consider offering assistance to the technology companies to improve performance and to ensure websites with quality information are shown higher in the search results.
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