Why Fall Is Worst Season for Your Child’s Asthma

After children head back to school, they go straight into peak virus season. If your child patients have asthma, this can exasperate the condition. It’s important to anticipate heightened symptoms and have a plan in place, says Giovanni Piedimonte, MD, Institute Chair for Pediatrics and staff physician for the Cleveland Clinic’s Center for Pediatric Pulmonary Medicine.

Fall and winter are the worst seasons for children with asthma because they become exposed to many more respiratory viruses as school resumes and they return to classrooms, Dr. Piedimonte says.

He warns parents and other doctors that children’s asthma may flare up in late August and September because of two key factors:

1.    Viral infections are more prevalent in the community, and that continues into the fall and winter.
2.    Children return to school and are in close quarters with other students with viruses.

“The fall/winter season is when we experience a very significant increase in asthma attacks,” says Dr. Piedimonte.

“That’s because viruses become highly prevalent in the population and typically cause upper respiratory infections. This, in turn, triggers asthma attacks.”

Throughout the changes of the seasons, children may have various allergies, depending on pollination and the blooming of various flowers and grasses. Allergic reactions can also spark asthma attacks, alone or in combination with other environmental factors like viruses and indoor and outdoor pollution.

Viruses are the real culprits
However, during the summer season, there are fewer asthma attacks because children are not exposed to as many potential viral infections and spend less time in the more densely populated school setting.

While some children and adults may suffer because of higher levels of humidity and pollution in the summer, the fall/winter season remains the most challenging because of the increase in exposure to viruses, Dr. Piedimonte says. Studies show that viruses cause more than 80 percent of asthma attacks, he says.

Here’s the usual progression, according to Dr. Piedimonte:
•    For the first three to five days, a child has an upper respiratory infection (URI), with a runny nose, congestion, sneezing and, sometimes, a low-grade temperature.
•    During the URI, the virus may spread down to the lower airways.
•    That generates inflammation and triggers obstruction of the airways, which are more reactive (“twitchy”) in children with...

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A Near Definitive Link Between Cigarette Smoke and Chronic Obstructive Pulmonary Disease

Patients with chronic obstructive pulmonary disease (COPD) often display inhibited mitochondrial protein pathways, according to a study published in the Journal of Clinical Investigation

Researchers from Brown University examined healthy patients’ and smoking patients’ lung samples in order to demonstrate that the expression of the pathways in immune responses is decreased in COPD patients. The researchers examined the relationship between NLRX1, the protein known to inhibit the MAVS/ RIG-1-like helicase pathway, in the clinical stage of current and former smokers with COPD. 

The team found that measured levels of the protein are a sign of cigarette induced emphysema, similar to the lung destruction that is seen in patients with COPD. 

“This is a new school of thought in terms of what causes emphysema and a new school of thought regarding how cigarette smoke does what it does,” corresponding author and pulmonologist Jack A. Elias, MD, dean of medicine and biological sciences at Brown University, explained in a press release. “We’re showing that a lot of what's going on is related to mitochondria.” 

Then, the investigators repeated a similar experiment in mice models. They were able to show a direct relationship between cigarette exposure, NLRX1, and the MAVS/ RIG-like helicase pathway. In this experiment, when the mice were exposed to smoke, they demonstrated lower levels of NLRX1 expression than the control mice which were not exposed. Mice that were biologically engineered to lack the gene for NLRX1 developed an advanced degree of emphysema when exposed to the cigarette smoke.

“Our observation is that NLRX1 is a critical inhibitor of MAVS/ RIG-like helicase signaling that is affected by cigarette smoking exposure,” said study lead author Min-Jong Kang, a researcher at both Yale and Brown, continued in the statement. “We observed that the levels of this molecule could explain diverse aspects of disease severity and patient’s symptoms.” 

Through even more experiments, the authors of the study solidified their hypothesis that NLRX1 is connected to the MAVS/ RIG-like helicase pathway in the context of cigarette smoke exposure in both human and mice models. 
However, there are still unanswered questions. Specifically, the researchers have yet to determine exactly how cigarette smoke suppresses NLRX1 in human subjects. One difference the scientists noted between humans and mice models of this experiment is that...

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Why Bacteria May Be a Future Smoking Cessation Aid

A bacterial enzyme may be a future candidate in smoking cessation, according to a new study led by researchers at The Scripps Institute. Findings from the study are published in the Journal of the American Chemical Society.
Current smoking cessation aids have proven to be ineffective in at least 80–90% of smokers. This novel enzyme therapy would be to eliminate nicotine before it reaches the brain as to not trigger a smoker into relapse. The NicA2 enzyme is found in the, which is originally from soil in a tobacco field. The bacteria consumes nicotine as its one source of carbon and nitrogen. Researchers set out to test its potential efficacy as a therapeutic agent.

The team combined serum from mice with a nicotine dose equivalent to one cigarette. When the enzyme was added, they found the nicotine's half-life was cut from 2–3 hours to just 9–15 minutes. A higher dose of the enzyme could decrease the half-life of nicotine even more and prevent it from reaching the brain. The team then tested the enzyme to assess its practicality as a drug candidate. The enzyme remained stable in the lab for over three weeks at 98 degrees Fahrenheit. Also, the scientists did not find any toxic metabolites produced when the enzyme broke down nicotine.

Future studies will include improving the enzyme's serum stability so that a single injection can last up to a month, researchers concluded.


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Blood lipid profile tied to childhood asthma and bronchial responsiveness

Blood lipid profiles are associated with childhood asthma, airway obstruction, bronchial responsiveness, and aeroallergen sensitization, researchers from Denmark report.

Dr. Hans Bisgaard from the University of Copenhagen told Reuters Health by email that he was surprised by the "significant association between serum lipids and asthma and allergy. This association is similar to the association found between serum lipids and other chronic inflammatory disorders."

Previous studies examining the relationship between the blood lipids and asthma have yielded ambiguous results, despite the association of hypercholesterolemia with a skewing of the adaptive immune response toward a TH2-oriented response, which is also seen in asthma and related disorders.

Dr. Bisgaard's team investigated the possible relationship between blood lipid levels, asthma, lung function, sensitization and allergic rhinitis in 296 7-year-old children born to mothers with a diagnosis of asthma.

Increasing LDL-cholesterol levels were associated with a 93% increase in the odds of concurrent asthma after adjustment and a significantly increased risk of airway obstruction, the researchers reported July 3 in the Journal of Allergy and Clinical Immunology.

In contrast, high HDL-cholesterol levels were associated with significantly improved airway flow, decreased bronchial responsiveness, 73% lower odds of sensitization against aeroallergens, and a non-significant reduced risk of allergic rhinitis.

High triglyceride levels were significantly associated with a doubling of the risk of aeroallergen sensitization, but not with the other measures.

Dr. Bisgaard said there are no immediate clinical implications of these findings.

"The study is seeking to understand the origins and mechanisms of chronic inflammatory disorders such as asthma and allergy," he said. "This insight will build the foundation for future prevention and treatment."

The researchers add, "Further longitudinal studies are required to evaluate a potential modifiable link between an unhealthy blood lipid profile and asthma and allergic sensitization."

Dr. Yang-Ching Chen from Taipei City Hospital in Taiwan, who was not involved in the new work, also found a link between LDL-cholesterol and asthma in an earlier study.

"Our data identified a trend of increasing levels of total cholesterol and LDL-cholesterol in the group order obese asthmatics > non-obese asthmatics > obese controls > non-obese...

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COPD Foundation Release: FDA Approves First COPD Biomarker

The COPD Foundation is extremely pleased to announce that a new clinical biomarker, plasma fibrinogen, has been approved for use in interventional clinical trials in patients with chronic obstructive pulmonary disease, the nation’s 3rd leading cause of death. This is the first COPD biomarker to receive qualification by the U.S. Food and Drug Administration (FDA) and is the result of six years of work by the COPD Biomarker Qualification Consortium (CBQC).

“Individuals working in the pharmaceutical industry, universities and the patient community have spent several million dollars and countless hours assembling and analyzing data that has led to the FDA’s monumental decision to approve this first COPD biomarker. Ultimately this clinical biomarker will enable future drug development to benefit patients.”

The CBQC, which includes representatives and resources from university and government research, pharmaceutical and patient communities, was created by the COPD Foundation in 2010, with encouragement from the FDA and the National Heart, Lung and Blood Institute, to develop a “biomarker qualification process” for COPD. Biomarkers are medical processes that researchers use to measure disease severity or to determine if a new drug or treatment is effective. Being able to use a biomarker qualified by the FDA assures drug developers that any potential new drug applications will not be rejected simply because of how the drug’s efficacy was measured or how patients were selected.

“This is a major triumph and, on behalf of the entire COPD community, I extend a heart-felt thank you to the FDA and congratulate the CBQC on its commitment and tireless leadership that allowed us to reach this significant milestone,” said John W. Walsh, co-founder and president of the COPD Foundation. “Individuals working in the pharmaceutical industry, universities and the patient community have spent several million dollars and countless hours assembling and analyzing data that has led to the FDA’s monumental decision to approve this first COPD biomarker. Ultimately this clinical biomarker will enable future drug development to benefit patients.”

COPD causes serious long-term disability and as many as 24 million Americans have the disease, but approximately half of them remain undiagnosed. On average, one American dies from COPD every 4 minutes yet in the last 3 decades, only one new class of drug has been approved for COPD.

For more information...

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In old age, current and former smokers face early lung disease

There may be 35 million older Americans with undiagnosed lung disease due to cigarette smoking, a new study suggests.

They don't meet the criteria for a diagnosis of chronic obstructive pulmonary disease (COPD), but they still suffer significant lung disease and impairment, the researchers report in JAMA Internal Medicine.

"We think we can increase their quality of life by treating them before they get worse," said Dr. James Crapo, the study's senior author from National Jewish Health in Denver.

Currently, about half of U.S. residents age 49 and older are current or former cigarette smokers, the researchers write.

About one in five U.S. adults currently smoke.

COPD, the third leading cause of death in the U.S., is often related to smoking, they add. The disease worsens with age and makes it more and more difficult to breathe.

Typically, the condition is diagnosed through spirometry, which measures lung function. But Crapo points out that lung function can be impaired to lesser degrees before people qualify for a COPD diagnosis.

For the new study, the researchers looked at data from people across the U.S. that had been gathered through spirometry, CT imaging scans of the chest, a walking test and questionnaires.

The researchers compared 4,388 people with normal spirometry tests to 794 people with mild COPD and 108 people who never smoked.

Overall, about 54 percent of people who had normal spirometry scores had signs of lung disease or impairment, the researchers found.

"I think to say they don’t have the disease is wrong," Crapo said.

Compared to the never smokers, those with normal spirometry but impaired lung function had worse quality of life scores, more trouble walking and evidence of airway thickening and emphysema on their CT scans.

The researchers suggest the current diagnostic criteria for COPD may not be picking up everyone with lung disease. Also, the criteria might not detect disease that is progressing in younger smokers.

"We don’t know how to prevent it yet, but the first step is identifying it early," Crapo said. "Then, trying to stop it from progressing."

For now, Crapo said old Americans may qualify for a free CT scan of their chest through Medicare, the public insurance program for older and disabled Americans.

While that scan can help doctors look for cancer, Crapo said it also reveals signs of COPD, such as thickening air walls.

"If you’re one of those people who smoked heavily in...

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 Level of e-cigarette power contributes to potentially hazardous effects

The higher the power of an e-cigarette, the higher the concentrations of potentially hazardous substances the device produces, including acetaldehyde, acrolein, and formaldehyde.

Those are among the findings presented at an international conference of the American Thoracic Society by lead study author Dr. Daniel Sullivan, an internal medicine resident at the University of Texas Southwestern Medical Center. During his previous training at the University of Alabama, Birmingham, Dr. Sullivan and his associates used a variety of methods including liquid chromatography–mass spectrometry and enzyme-linked immunosorbent assay (ELISA) to study components and nicotine formulations typical of e-cigarette users.

Under some test conditions, formaldehyde levels were comparable to those seen in traditional tobacco cigarettes, he said in a video interview.



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Study shows cost-effective expert recommended asthma test underutilized by physicians

Researchers from the University of Texas Medical Branch at Galveston have found, for the first time, that spirometry was underutilized for asthma diagnosis and management in U.S. adults from 2001 to 2011, despite it's accuracy, cost effectiveness and the publication of national guidelines advocating its use.

Spirometry is a common test that allows physicians to determine how well a person's lungs work by measuring how much air is inhaled and exhaled as well as how quickly the air is exhaled. This test plays a vital role in the diagnosis and management of asthma by providing accurate measurements of air volumes and flows.

The Choosing Wisely initiative of the American Board of Internal Medicine Foundation helps physicians and patients work together to make appropriate, effective and cost-effective health care choices.

Asthma affects about 8 percent of U.S. adults, which cost $56 billion in medical care in 2007. The Choosing Wisely initiative recommends spirometry for diagnosis and follow-up asthma care because it's effective and costs about $42. On the other hand, unnecessary use of an inhaler can cost $200 to $300 a month. An emergency room visit for an asthma episode can total $3,500. Health care use, including emergency department visits and hospitalizations are linked with how well asthma is controlled. Thus, when used in the diagnosis and management of asthma at the recommended times, spirometry should prevent needless expense.

This study evaluated trends, from 2001 to 2011, in the use of spirometry in patients within a year of when they were diagnosed with asthma. The findings are detailed in the American Journal of Medicine.

In all, 134,208 asthma patients were included in the study. Only 48 percent had spirometry performed within one year of diagnosis. Younger patients, males and those residing in the Northeast were more likely to receive spirometry. Eighty percent of patients cared for by specialists received spirometry, while only 23 percent of those cared for by primary care physicians underwent the test. However, even without spirometry, close to 80 percent of patients were prescribed asthma drugs.

"Physicians must be educated about the usefulness of spirometry and given evidence of its medical and monetary value," said Dr. Kristin Sokol, assistant professor of pediatrics in the division of allergy and immunology. "As the Choosing Wisely initiative implies, the underuse of spirometry may lead to misdiagnosis or under...

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