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Medical Journal Review

September 2018

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 from Juan Carlos Ivancevich, MD, WAO Web Managing Editor, and summary author, John J. Oppenheimer, MD, FACAAI, FAAAAI, WAO Reviews Editor.

Eosinophils increase airway sensory nerve density in mice and in human asthma
Drake MG, Scott GD, Blum ED, Lebold KM, Nie Z et al
Science Translational Medicine 2018; 10(457):eaar8477. DOI: 10.10.1126/scitranslmed.aar8477

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It is well known that airway nerve dysfunction leads to excessive bronchoconstriction and that eosinophils alter nerve function, with airway eosinophilia being present in 50 to 60% of asthmatics. Yet the effects of eosinophils on airway nerve structure have not been established. Thus, the authors examined if eosinophils alter airway nerve structure and measured the physiological consequences of those changes examining both humans and mice. They demonstrated that in humans with and without eosinophilic asthma, airway innervation and substance P expression were increased in moderate persistent asthmatics compared to mild intermittent asthmatics and healthy subjects. Furthermore, increased innervation was associated with a lack of bronchodilator responsiveness and increased irritant sensitivity. Using a mouse model they found an increase in nerve density and airway hyperresponsiveness were mediated by eosinophils. They conclude that airway nerve remodeling is likely a key mechanism for increased irritant sensitivity and exaggerated airway responsiveness in eosinophilic asthma.

Daily allergic multimorbidity in rhinitis using mobile technology: A novel concept of the MASK study
Bousquet J, Devillier P, Anto JM, Bewick M, Haahtela T et al
Allergy 2018; 73(8):1622-1631. Published online ahead of print (24 March). DOI: 10.111/all.1348.

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To better understand the impact of multimorbidity’s (i.e., asthma, conjunctivitis, and rhinitis) impact on work productivity the authors performed a 1-year prospective observational study in which 4,210 patients used a mobile technology (the Allergy Diary) which examined 5 visual analogue scales (VAS) to assess the daily burden of the disease (i.e., global evaluation, nose, eyes, asthma and work). Using this novel approach, they found considerable intra-individual variability of allergic multimorbidity including a previously unrecognized extreme pattern of uncontrolled multimorbidity. Furthermore, the authors suggest that big data will soon be coming to the study of allergic diseases and should be considered differently than the classical approach; however, this approach will likely complement our current knowledge and aid in optimizing our practice of allergy.

Clinical decision support systems for drug allergy checking: Systematic review
Légat L, Van Laere S, Nyseen M, Steurbaut S, Dupont AG, Cornu P
Journal of Medical Internet Research 2018; 20(9):e258. DOI: 10.2196/jmir.8206

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Medication errors, such as providing a medication that the patient is allergic to, can have very dire consequences. Computerized physician order entry systems with built-in clinical decision support systems (CDSS) have the potential to prevent such medication errors and adverse events. In this review, Légat and colleagues explore through systematic review what procedures can be used of optimize care for the drug allergic patient. Although accurate and comprehensive recording of drug allergies is required for good use of CDSS for drug allergy screening, they found considerable variation in the way drug allergies are recorded in EHRs. Also, it remains difficult to reduce drug allergy alert overload while maintaining patient safety as the highest priority. They conclude by suggesting that further research should focus on improving alert specificity, thereby reducing override rates and alert fatigue and they reinforce that the effect on patient outcomes and cost-effectiveness should also be evaluated.

Age at puberty and risk of asthma: A Mendelian randomization study
Minelli C, van der Plaat DA, Leynaert B, Granell R, Amaral AFS et al
PLoS Medicine 2018; 15(8):e1002634. DOI: 10.1371/journal.pmed.1002634.

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Previous observational studies regarding pubertal timing and asthma, mainly performed in females, have provided conflicting results about a possible association of early puberty with higher risk of adult asthma, possibly due to residual confounding. To overcome issues of confounding, Minelli et al., relied upon Mendelian randomization to estimate causal effects of early puberty on post-pubertal asthma in both females and males by utilizing a UK Biobank, analyzing data on approximately 240,000 women and approximately 190,000 men with available genetic data and self-reported information on asthma and age at puberty (menarche for women and voice breaking for men). They found that both women and men with early puberty had an increased risk of asthma of 8% and 7%, respectively. On the other hand, there was no evidence of a detrimental effect of late puberty on asthma. The authors note that the similarity of findings in both females and males might be explained by common biological or psychological factors related to early puberty, but further research is needed to elucidate this/these mechanism(s).

Prevalence of allergic sensitization, hay fever, eczema, and asthma in a longitudinal birth cohort
Owens L, Laing IA, Zhang G, Turner S, Le Souef PN
Journal of Asthma and Allergy 2018; 11:173-180. DOI: 10.2147/JAA.S170285

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In this study, Owens and colleagues longitudinally assessed the prevalence of allergic sensitization, asthma, eczema and hay fever from infancy to adulthood in a single birth cohort of 253 participants recruited from an urban maternity hospital, with respiratory and immunological assessments performed at 1, 6, 11, 18 and 24 years of age. Overall, they found that patterns of atopic disorders vary throughout childhood; however, the prevalence of allergic sensitization and hay fever rose throughout childhood while the prevalence of asthma reduced. Specifically, they found that the prevalence of allergic sensitization rose from 19% (n=33) at 1 year of age to 71% (n=77) at 24 years of age. The rate of asthma halved from 25% at 6 years of age to 12%–15% between 11 and 24 years of age, while the prevalence of allergic sensitization among those with asthma doubled from 50% at 6 years of age to 100% at 24 years of age. Hay fever rates rose throughout childhood from 7% at 6 years of age to 44% at 24 years of age, while the prevalence of eczema diminished from 25% at 6 years of age to 16% at 24 years of age. When looking for potential risk associations, they found that parental atopy doubled the odds of asthma in their offspring by 24 years of age (odds ratio [OR] = 2.63, 95% CI\ 1.1–6.2, p=0.029), the relationship between eczema and asthma was only significant up to 11 years of age, and the relationship between hay fever and asthma was stronger in adolescence and early adulthood than in early childhood.