Atopic cough and fungal allergy

Juan Carlos Ivancevich Thursday, 13 November 2014 15:24

Keynote Lecture

Haruhiko Ogawa1, Masaki Fujimura2, Noriyuki Ohkura3, Koichi Makimura4

1Division of Pulmonary Medicine, Ishikawa-ken Saiseikai, Kanazawa Hospital, Kanazawa 920-0353, Japan; 2Respiratory Medicine, National Hospital Organization Nanao Hospital, Nanao 926-8531, Japan; 3Ishikawa Prefectural Central Hospital, Respiratory Medicine, Kanazawa, Japan; 4Laboratory of Space and Environmental Medicine, Graduate School of Medicine and Graduate School of Medical Technology, Teikyo University, Itabashi-ku Tokyo, Japan

Correspondence to: Haruhiko Ogawa, MD, PhD. Division of Pulmonary Medicine, Ishikawa-ken Saiseikai Kanazawa Hospital, Ni-13-6 Akatsuchi-machi, Kanazawa 920-0353, Japan. Email: This email address is being protected from spambots. You need JavaScript enabled to view it. .

Abstract: We have shown that some patients presenting with chronic bronchodilator-resistant non-productive cough have a global atopic tendency and cough hypersensitivity without nonspecific bronchial hyperresponsiveness, abbreviated as atopic cough (AC). The cough can be treated successfully with histamine H1 antagonists and/or glucocorticoids. Eosinophilic tracheobronchitis and cough hypersensitivity are pathological and physiological characteristics of AC. Fungus-associated chronic cough (FACC) is defined as chronic cough associated with basidiomycetous (BM) fungi found in induced sputum, and recognition of FACC has provided the possibility of using antifungal drugs as new treatment strategies. Bjerkandera adusta is a wood decay BM fungus, which has attracted attention because of its potential role in enhancing the severity of cough symptoms in FACC patients by sensitization to this fungus. Before making a diagnosis of “idiopathic cough” in cases of chronic refractory cough, remaining intractable cough-related laryngeal sensations, such as “a sensation of mucus in the throat (SMIT),” which is correlated with fungal colonization, should be evaluated and treated appropriately in each patient. The new findings, i.e., the detection of environmental mushroom spores that should not be present in the human airways in addition to the good clinical response of patients to antifungal drugs, may lead to the development of novel strategies for treatment of chronic cough.

Keywords: Atopic cough (AC); cough variant asthma (CVA); fungus-associated chronic cough (FACC); Bjerkandera adusta; cough-related laryngeal sensations

doi: 10.3978/j.issn.2072-1439.2014.09.25

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Childhood Asthma-Predictive Phenotype

Juan Carlos Ivancevich Tuesday, 11 November 2014 13:13

Wheezing is a fairly common symptom in early childhood, but only some of these toddlers will experience continued wheezing symptoms in later childhood. The definition of the asthma-predictive phenotype is in children with frequent, recurrent wheezing in early life who have risk factors associated with the continuation of asthma symptoms in later life. Several asthma-predictive phenotypes were developed retrospectively based on large, longitudinal cohort studies; however, it can be difficult to differentiate these phenotypes clinically as the expression of symptoms, and risk factors can change with time. Genetic, environmental, developmental, and host factors and their interactions may contribute to the development, severity, and persistence of the asthma phenotype over time. Key characteristics that distinguish the childhood asthma-predictive phenotype include the following: male sex; a history of wheezing, with lower respiratory tract infections; history of parental asthma; history of atopic dermatitis; eosinophilia; early sensitization to food or aeroallergens; or lower lung function in early life.

The Journal of Allergy and Clinical Immunology: In Practice Volume 2, Issue 6, Pages 664–670, November–December, 2014

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The Allergic Asthma Phenotype

Juan Carlos Ivancevich Thursday, 06 November 2014 13:07

Michael Schatz, MD, MSThis email address is being protected from spambots. You need JavaScript enabled to view it.
Lanny Rosenwasser, MD
 
Abstract
Allergic asthma is the most common asthma phenotype. It usually is defined by the presence of sensitization to environmental allergens, although a clinical correlation between exposure and symptoms further supports the diagnosis. The average age of onset of allergic asthma is younger than that of nonallergic asthma. Although the spectrum of allergic asthma may vary from mild to severe, studies have reported that allergic versus nonallergic asthma is less severe. There is an increased prevalence of allergic rhinoconjunctivitis and atopic dermatitis in patients with allergic asthma. Total IgE levels usually are higher in allergic versus nonallergic asthma, but levels substantially overlap between the 2 groups. Increased Th2 cytokines have been demonstrated in secretions and peripheral blood of patients with allergic asthma. Atopy has been reported to be inversely associated with persistent airflow obstruction and airway remodeling. Clusters with a high prevalence of early onset atopic asthma have been frequently reported in statistical phenotyping studies, but the various clusters of patients with atopy were quite heterogeneous in terms of symptom severity, pulmonary function, and tendency for exacerbations. Implications for future research regarding the allergic asthma phenotype are described.
 

 

Inhaler reminders improve adherence with controller treatment in primary care patients with asthma

Juan Carlos Ivancevich Tuesday, 11 November 2014 12:58

Abstract

BACKGROUND: Poor adherence contributes to uncontrolled asthma. Pragmatic adherence interventions for primary care settings are lacking.

OBJECTIVE: To test the effectiveness of 2 brief general practitioner (GP)-delivered interventions for improving adherence and asthma control.

METHODS: In a 6-month cluster randomized 2 × 2 factorial controlled trial, with GP as unit of cluster, we compared inhaler reminders and feedback (IRF) and/or personalized adherence discussions (PADs) with active usual care alone; all GPs received action plan and inhaler technique training. GPs enrolled patients prescribed combination controller inhalers, with suboptimal Asthma Control Test (ACT) scores (ACT score ≤19). Inhaler monitors recorded fluticasone propionate/salmeterol adherence (covertly for non-IRF groups) and, in IRF groups, provided twice-daily reminders for missed doses, and adherence feedback. PAD GPs received communication training regarding adherence. Outcomes collected every 2 months included ACT scores (primary outcome) and severe exacerbations. Intention-to-treat mixed-model analysis incorporated cluster effect and repeated measures.

RESULTS: A total of 43 GPs enrolled 143 patients with moderate-severe asthma (mean age, 40.3 ± 15.2 years; ACT score, 14.6 ± 3.8; fluticasone propionate dose, 718 ± 470 μg). Over 6 months, adherence was significantly higher in the IRF group than in non-IRF groups (73% ± 26% vs 46% ± 28% of prescribed daily doses; P < .0001), but not between PAD and non-PAD groups. Asthma control improved overall (mean change in ACT score, 4.5 ± 4.9; P < .0001), with no significant difference among groups (P = .14). Severe exacerbations were experienced by 11% of the patients in IRF groups and 28% of the patients in non-IRF groups (P = .013; after adjustment for exacerbation history; P = .06).

CONCLUSIONS: Inhaler reminders offer an effective strategy for improving adherence in primary care compared with a behavioral intervention or usual care, although this may not be reflected in differences in day-to-day asthma control.

KEYWORDS: Medication adherence; ambulatory monitoring; antiasthmatic agents; asthma; health communication; intervention studies; treatment effectiveness


J Allergy Clin Immunol. 2014 Jul 18. pii: S0091-6749(14)00802-1. doi: 10.1016/j.jaci.2014.05.041. [Epub ahead of print]

 

Asthma Phenotypes: Nonallergic (Intrinsic) Asthma

Juan Carlos Ivancevich Thursday, 06 November 2014 12:53
 
Stephen P. Peters, MD, PhD, FAAAAIThis email address is being protected from spambots. You need JavaScript enabled to view it.
Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, NC

Abstract

The definition of nonallergic asthma includes that subset of subjects with asthma and with whom allergic sensitization cannot be demonstrated. These individuals should have negative skin prick test or in vitro specific-IgE test to a panel of seasonal and perennial allergens. Nonallergic asthma occurs in 10% to 33% of individuals with asthma and has a later onset than allergic asthma, with a female predominance. Nonallergic asthma appears to be more severe than allergic asthma in many cases and may be less responsive to standard therapy. Although many of the immunopathologic features of nonallergic asthma are similar to those observed with allergic asthma, some differences have been described, including a higher expression of RANTES in mucosa and bronchoalveolar lavage fluid, as well as a higher GM-CSF receptor alpha expression. Unbiased statistical methods, such as cluster analysis and latent class analysis, indicate that the lack of atopy is not the most important defining factor in assigning an individual to many specific phenotypes but rather is more important in some phenotypes than others, and appears to modulate the clinical expression of the disease. Despite an appreciation of this clinical entity for many years, many of its clinical implications remain unclear.

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Editor: Juan C. Ivancevich, MD

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