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Medical Journal Review

July 2015

WAO Reviews - Editors' Choice

The Editors select articles for their importance to clinicians who care for patients with asthma and allergic/immunologic diseases, and whenever possible they seek articles that everyone can access freely. The Editors' Choice comes to you each month from Juan Carlos Ivancevich, MD, WAO Web Editor-in-Chief, and John J. Oppenheimer, MD, FACAAI, FAAAAI, the WAO Reviews Editor.

1. The immune response that occurs in patients with severe asthma is markedly different than what occurs in milder forms.

Raundhal M, Morse C, Khare A, Oriss TB, Milosevic J et al. High IFN-γ and low SLPI mark severe asthma in mice and humans. Journal of Clinical Investigation 2015; published online ahead of print, 25 June. (doi:10.1172/JCI80911)

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Editor’s comment: The authors observed that CD4 T-cells in the airways of severe asthmatics secreted different inflammatory proteins than those with mild disease – particularly interferon gamma. The analysis of human samples helped them to develop a mouse model of the disease. They introduced an allergen and a bacterial product to induce an immune profile and airway hyper-reactivity that were poorly controlled by corticosteroids and are comparable to human severe asthma patients. Through this model, the investigators found that boosting secretory leukocyte protease inhibitor (SLPI) levels reduced airway hyper-reactivity.

2. An updated and comprehensive review about contact dermatitis.

Fonacier L, Bernstein DI, Pacheco K, Holness DL, Blessing-Moore J et al. Contact dermatitis: a practice parameter-update. JACI: In Practice 2015; 3(3): S1–S39. (doi:10.1016/j.jaip.2015.02.009)

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Editor’s comment: This is a complete and comprehensive document regarding the diagnosis and treatment of contact dermatitis. The Joint Task Force on Practice Parameters, which represents the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma & Immunology developed this parameter.

3. Relationship between patient information and adherence to allergen immunotherapy in clinical practice.

Calderon MA, Cox L, Casale TB, Mösges R, Pfaar O et al. The effect of a new communication template on anticipated willingness to initiate or resume allergen immunotherapy: an internet-based patient survey. Allergy, Asthma & Clinical Immunology 2015; 11:17. (doi:10.1186/s13223-015-0083-z)

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Editor’s comment: In attempt to assess patients’ understanding of allergy and acceptance of allergen immunotherapy, the authors performed an Internet-based survey of patient panels in France, Germany, Spain, the United States and Russia. The survey participants had either recently discontinued allergen immunotherapy before the end of the prescribed course or decided not to initiate a course of allergen immunotherapy recommended by their physician.  Participants completed an online questionnaire immediately before and after viewing a recently developed communication template, in an attempt to validate the template and to assess its impact on anticipated willingness to initiate or resume allergen immunotherapy.  They found that sixty-seven percent of participants stated that viewing the communication template would have made them more likely to continue or initiate allergen immunotherapy. They also demonstrated that early abandoners reported a perception of low effectiveness (39 %) and complained about expense (39 %) and practical constraints (32 %), while the non-starters feared side effects (22%).

4. Infliximab systemic adverse reactions and desensitization.

Mourad AA, Boktor MN, Yilmaz-Demirdag Y, Bahna SL. Adverse reactions to infliximab and the outcome of desensitization. Annals of Allergy, Asthma & Immunology 2015; published online ahead of print, 17 June. (doi:http://dx.doi.org/10.1016/j.anai.2015.06.004)

Abstract

Editor’s comment: The authors aimed to investigate the frequency and characteristics of adverse reactions to infliximab at the authors' institution and the outcome of their management, including desensitization. They found that Infliximab can trigger systemic reactions and that in such cases desensitization appears to be safe and effective.

5. Small-particle inhaled corticosteroids (ICS) in pediatric asthma.

van Aalderen WM, Grigg J, Guilbert TW, Roche N, Istael E et al. Small-particle inhaled corticosteroid as first-line or step-up controller therapy in childhood asthma. JACI: In Practice 2015, published online ahead of print, 29 May. (doi:http://dx.doi.org/10.1016/j.jaip.2015.04.012)

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Editor’s comment: The authors compared the effectiveness of a small-particle inhaled corticosteroid (ICS) with that of standard size-particle ICS for children initiating or stepping up ICS therapy for asthma and also compared the effectiveness of ICS dose step-up using small-particle ICS with adding long-acting β2-agonist (LABA) to the ICS. They found that initiating or stepping up the ICS dose with small-particle ICS rather than with standard size-particle, ICS was more effective and showed similar effectiveness to add-on LABA in childhood asthma.

6. Review article on chromium.

Bregnbak D, Johansen JD, Jellesen MS, Zachariae C, Menné T, Thyssen JP. Chromium allergy and dermatitis: prevalence and main findings. Contact Dermatitis 2015; published online ahead of print, 24 June. (doi:10.1111/cod.12436)

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Editor’s comment: This review article focuses on chromium’s allergenic properties, its potential exposure sources, specifically examining its impact on the skin. This article also provides an overview of the regulations regarding its use, and it analyzes the epidemiological pattern between nations and across continents. The authors provide an update on the allergen from a dermatological point of view, and they conclude that much still remains to be discovered about the allergen and that continued surveillance of exposure sources and prevalence rates are necessary.

7. Achieving asthma control requires implementation of evidence-based guidelines and further research into severe asthma.

Papaioannou AI, Kostikas K, Zervas E, Kolilekas L, Papiris S, Gaga M. Control of asthma in real life: still a valuable goal? European Respiratory Review 2015; 24(136): 361-369. (doi:10.1183/16000617.000016)

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Editor’s comment: This is a wonderful review of the literature regarding asthma control.  The authors note that despite significant strides in our understanding and treatment of asthma, we are not able to achieve adequate control in a significant proportion of our asthmatic patients. The authors point out that we need to implement strategies to better define asthma control, as well as to identify means for the refinement of the communication of the meaning of asthma control and its elements between patients and doctors. They further note that biomarkers may represent an option for better objective evaluation and implementation of control in asthma management, but further research is needed. Lastly, they stress that the biggest challenge we face is severe asthma, where even the optimization of treatment with the effective medications we have today does not achieve control of asthma and thus suggest focused research into the mechanisms of severe asthma and that new targeted treatments must be a high priority.

8. Consensus on the mechanisms of exercise-induced anaphylaxis.

Ansley L, Bonini M, Delgado L, Del Giacco S, Du Toit G et al. Pathophysiological mechanisms of exercise-induced anaphylaxis: an EAACI position statement. Allergy 2015; published online ahead of print 8 July. (doi:10.1111/all.12677)

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Editor’s comment:  A multidisciplinary panel of experts including exercise physiologists, allergists, lung physicians, pediatricians and a biostatistician were assembled to produce this consensus document regard exercise-induced anaphylaxis (EIAn). The panel agreed that the pathophysiological mechanisms underlying EIAn have not yet been elucidated, although a number of hypotheses have been proposed. The group went on to evaluate the validity of each of the popular theories in relation to exercise physiology and immunology and concluded that on the basis of this evidence the proposed mechanisms lack validity.  They thus recommended that a global research network be developed with a common approach to the diagnosis and treatment of EIAn in order to gain sufficient power for scientific evaluation.

9. Activin A plays an important role in the regulation of asthmatic inflammation and airway remodelling.

Hardy CL, Rolland JM, O'Hehir RE. The immunoregulatory and fibrotic roles of activin A in allergic asthma. Clinical & Experimental Allergy 2015; published online ahead of print, 12 May. (doi:10.1111/cea.12561).

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Editor’s comment: This review examines the activin A/TGF-β superfamily, focusing on the regulation of receptors and signaling pathways. The authors explore the contradictory evidence for generalized pro- versus anti-inflammatory effects of activin A in inflammation, focusing on its role in asthmatic inflammation and airway remodeling.

10. Assessing small airways dysfunction (SAD).

Postma DS, Brightling C, Fabbri L, van der Molen T, Nicolini G et al. Unmet needs for the assessment of small airways dysfunction in asthma: introduction to the ATLANTIS study. European Respiratory Journal 2015; 45(6): 1534–1538. (doi:10.1183/09031936.00214314)

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Editor’s comment: In this interesting editorial the authors reviewed the methods to assess small airways dysfunction (SAD) and present the ongoing ATLANTIS study (AssessmenT of smalL Airways involvemeNT In aSthma) to answer the unmet need of better understanding the contribution of SAD across all asthma severities and determine the best test(s) to identify SAD.