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Medical Journal Review

November 2019

WAO Reviews – Editors' Choice

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. They select articles for their importance to clinicians who care for patients with asthma and allergic/immunologic diseases, and whenever possible, for their accessibility to everyone.

Being overweight in childhood, puberty, or early adulthood: Changing asthma risk in the next generation?
Johannessen A, Lønnebotn M, Calciano L, Benediktsdóttir B, Bertelsen RJ et al.
Journal of Allergy and Clinical Immunology 2019; Published online ahead of print (7 Sept). doi:10.1016/j.jaci.2019.08.030

It is known that being overweight is a risk factor for asthma, but it is not known whether it might also increase asthma risk in the next generation. In this study, the authors examined whether parents being overweight in childhood, adolescence, or adulthood is associated with asthma in their offspring. To do so, they mined data from 6347 adult offspring (ages 18-52 years) of the Respiratory Health in Northern Europe, Spain and Australia (RHINESSA) multigeneration study of 2044 fathers and 2549 mothers (ages 37-66 years) investigated in the European Community Respiratory Health Survey (ECRHS) study. They found statistically significant associations between both fathers’ and mothers’ childhood overweight status and offspring’s childhood overweight status (odds ratio, 2.23 [95% CI, 1.45-3.42] and 2.45 [95% CI, 1.86-3.22], respectively). They also found a statistically significant effect of fathers’ onset of being overweight in puberty on offspring’s asthma without nasal allergies (relative risk ratio, 2.31 [95% CI, 1.23-4.33]).

Simulation of health and economic benefits of extended observation of resolved anaphylaxis
Shaker M, Wallace D, Golden DBK, Oppenheimer J, Greenhawt M
JAMA Network Open 2019;2(10):e1913951. doi:10.1001/jamanetworkopen.2019.13971

It is known that a biphasic component may occur in up to 20% of patients with anaphylaxis; however, the optimal observation time of patients with resolved anaphylaxis is unknown, but some suggest at least a 6-hour observation time after an anaphylactic episode. In this study the authors performed an economic evaluation via a computer simulation of adult patients observed in outpatient allergy clinics and emergency departments, with rates of biphasic anaphylaxis derived from a 2019 meta-analysis. Through this analysis, they found that routine prolonged medical observation of completely resolved episodes of anaphylaxis, to prevent a biphasic reaction, is not cost-effective. As noted in this article, it is important that all patients with anaphylaxis should be educated regarding the risk of a biphasic reaction and understand home management and thresholds for further care. Furthermore, those patients with risk factors that indicate a greater likelihood of biphasic anaphylaxis or higher fatality risk may benefit from more extended observation of up to 6 hours (and possibly longer in some circumstances). Conversely, it may be reasonable to discharge low-risk patients after a 1-hour observation period following resolved anaphylaxis.

Recent developments and highlights in immune monitoring of allergen immunotherapy
van Zelm MC, McKenzie CI, Varese N, Rolland JM, O’Hehir RE
Allergy 2019; Published online ahead of print (6 Oct). doi:10.1111/all.14078

Currently, the only corrective treatment available for allergic disease is allergen immunotherapy (AIT). AIT modifies the immune response through long-term repeated exposure to defined doses of allergen. However, as the treatment usually needs to be continued for several years to be effective, and it can be accompanied by adverse reactions, many patients face difficulties completing their schedule. Furthermore, long-term therapy can be costly. Therefore, there is a great need for objective markers to predict or to monitor individual patient’s beneficial changes in immune response during therapy to aid in identifying those likely to gain benefit as soon as possible. In this review, the authors explore recent developments that have generated new insights into allergic disease pathogenesis and how these could potentially be translated into routine laboratory assays for disease monitoring during AIT.

Association of occupational exposure to disinfectants with incidence of chronic obstructive pulmonary disease among US female nurses
Dumas O, Varraso R, Boggs KM, Quinot C, Zock JP et al.
JAMA Network Open 2019;2(10):e1913563. doi:10.1001/jamanetworkopen.2019.13563

While there have been data regarding the exposure to disinfectants in health care workers and respiratory illness including asthma, interestingly, there is a paucity of data regarding the potential impact on chronic obstructive pulmonary disease (COPD). To investigate the association between exposure to disinfectants and COPD incidence in a large cohort of US female nurses, the authors mined the Nurses’ Health Study II, which is a US prospective cohort study of 116,429 female registered nurses from 14 US states who were enrolled in 1989 and followed up through questionnaires every 2 years since. This study included women who were still in a nursing job and had no history of COPD in 2009, using data from the 2009 through 2015 questionnaires. They found that among the 73,262 women included in the analyses, including 368,145 person-years of follow-up, 582 nurses reported incident physician-diagnosed COPD. Weekly use of disinfectants to clean surfaces only (16,786 [22.9%] of participants exposed) and to clean medical instruments (13,899 [19.0%] exposed) was associated with COPD incidence, with adjusted hazard ratios of 1.38 (95%CI, 1.13-1.68) for cleaning surfaces only and 1.31 (95%CI, 1.07-1.61) for cleaning medical instruments after adjustment for age, smoking (pack-years), race, ethnicity, and body mass index. High-level exposure, evaluated by a job-task exposure matrix, to several specific disinfectants (i.e., glutaraldehyde, bleach, hydrogen peroxide, alcohol, and quaternary ammonium compounds) was significantly associated with COPD incidence, with adjusted hazard ratios ranging from 1.25 (95%CI, 1.04-1.51) to 1.36 (95%CI, 1.13-1.64). Interestingly, these associations were not modified by smoking or asthma status (P for interaction > .15).

Complexity in assessing the benefit vs risk of vaccines: Experience with rotavirus and dengue virus vaccines
Meissner HC
JAMA 2019; Publishing online ahead of print (17 Oct). doi:10.1001/jama.2019.16206

Despite the remarkable contribution that immunization programs have provided public health, some still express vaccine hesitancy. The author of this “viewpoint” notes that vaccine hesitancy often is predicated on the concern of an individual or family members regarding the risk of an adverse event following immunization. It is well known that for each licensed vaccine, the relative risk of an untoward event, such as contracting the disease, is greater among those who remain unvaccinated; and before receiving FDA licensure, vaccine safety must be determined by demonstration that the benefit from disease prevention exceeds the risk of adverse reactions associated with the vaccine. However, this assessment is not always straightforward, and the societal perspective of regulatory and advisory bodies may not always be in tandem with the individual perspective (patient or parent). In this paper the authors explore lessons learned by examining the literature regarding rotavirus and the dengue virus vaccine.

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