Don’t light up! Is This Your New Year’s Resolution?

This is a New Year’s resolution you love to hate.  Success rates for smokers may not look all that great, but you triple your chances of being a “quitter” if you use medications combined with counseling.  This article has lots of quotes that I left as is. 

Despite the known dangers of smoking, about 20 percent of Americans still light up, but almost 70 percent want to quit, a new government report shows.

“This study is reassuring to us,” Dr. Tim McAfee, director of the Office on Smoking and Health at the U.S. Centers for Disease Control and Prevention.
 
There was a concern that there was a group of smokers who would remain smokers and not be interested in quitting, but, “in fact, what this study shows is quite the opposite,” McAfee said.

The percentage of smokers appears to hover around 20 percent as people take up the habit, he said. “But there has been a decline in the last five years in the rate of smoking, and smokers are actually smoking less,” he added.

“Perhaps the most dangerous situation we are in is we have seen over the past five years a flattening of the downward trend in youth initiation. We are very worried that there are a number of things that have been happening in terms of tobacco industry marketing techniques that affect youth,” McAfee said.

The report was published in the Nov. 11 issue of the CDC‘s Morbidity and Mortality Weekly Report.

According to the report, 68.8 percent of current smokers say they want to quit and 52.4 percent tried to quit during the past year.

In addition, 48.3 percent of smokers who saw their doctor in the past year say they got advice to quit. Moreover, 31.7 percent had counseling alone or with drugs to help them quit in the past year. And about 6 percent quit successfully in the past year. 

McAfee noted that most smokers who manage to quit do so without the help of drugs or counseling. “About 20 percent of people take medication or sign up for counseling,” he said.

Other factors that are equated with quitting are education, where 11 percent of those with a college degree were able to quit, compared with 3 percent of those who did not graduate from high school, McAfee said.

In addition, blacks had the highest interest in quitting and the highest quit attempt rate than any other group, but blacks also had the lowest rate of successful quitting, McAfee said. Blacks were also less likely to use medication or counseling, he noted.

In addition, blacks were more likely to smoke menthol cigarettes, which decreases the rate of quitting, McAfee said.

If you can’t quit by yourself, the best way to quit is with a combination of counseling and drugs like Zyban, Chantix or other nicotine replacement therapy, the CDC report said.

“Smokers who try to quit can double or triple their chances by getting counseling, medicine or both,” CDC director Dr. Thomas R. Frieden said in a statement.

The CDC is releasing the report as part of the annual Great American Smokeout on Nov. 17. The event is sponsored by the American Cancer Society, and encourages smokers to make a plan to quit, or quit smoking that day.

The report also notes that the growth of smoke-free workplaces and public places offer smokers another incentive to quit.

Smoking is still the leading preventable cause of death and disease, including cancer, chronic obstructive pulmonary disease and other lung diseases. Each year in the United States, smoking and exposure to secondhand smoke kill some 443,000 people, the report noted.

In addition, for every smoking-related death there are 20 people living with a smoking-related disease, the agency said.

Vince Willmore, vice president of the Campaign for Tobacco-Free Kids, said that “the CDC report confirms that most smokers want to quit, but too many don’t get the help they need to succeed.”

“To help more smokers quit, it is critical that all private and government health plans provide affordable and accessible coverage for smoking-cessation medication and counseling, and that states use more of their tobacco revenues to properly fund tobacco prevention and cessation programs,” he said.

States must also continue to enact policies that encourage quitting, including higher tobacco taxes and smoke-free air laws, Willmore said.

In a related move, the U.S. Food and Drug Administration said Thursday that most of the warning letters it recently sent to more than 1,200 tobacco retailers were about illegal sales of cigarettes and smokeless tobacco products to minors.

FDA inspections of tobacco retailers found that most are in compliance with the law, but some still sell tobacco products to youngsters. Retailers who continue to violate the law could face fines.

“It should worry every parent that 20 percent of U.S. high school students smoke cigarettes,” FDA Commissioner Margaret A. Hamburg said in an agency news release.

“For many young people, that first cigarette or use of smokeless tobacco will lead to a lifetime of addiction, and for many, serious disease,” she said. “More than 80 percent of adult smokers begin smoking before 18 years of age. Retailers are vital partners in the FDA’s efforts to prevent tobacco use among kids.”

With all this bad news, is there anything that can be done?  Oklahoma State University is now a smoke-free campus since 2008–way to go Pokes! 

#american-cancer-society, #cdc, #centers-for-disease-control-and-prevention, #margaret-a-hamburg, #mcafee, #morbidity-and-mortality-weekly-report, #tom-frieden, #united-states

Am I Allergic to the Cold?

It’s January and thank goodness no blizzard like last year in Oklahoma!  But…can you be allergic to the cold?  Every year, I evaluate 1 or 2 patients with “cold-induced” urticaria and today was that day.  The following video is from Mayo clinic, but this condition can and does happen in Oklahoma.

Here is a link to USAToday and the same condition–>Allergic to Cold!

#allergy, #contact-dermatitis, #insect-bites-and-stings, #mayo-clinic, #oklahoma, #skin, #united-states, #urticaria

Genetic Research in Asthma

Researchers look to genetics to understand African American-asthma link

Genetic map of 1,000 African Americans mapped for asthma research
 By Meredith Cohn7:00 a.m. EST, December 29, 2011
 For the full link, click here.

Researchers working to discover why African-Americans disproportionately suffer from asthma are planning to map the genetic code of 1,000 people of African descent in four years.

The Johns Hopkins-led team of experts in genetics, immunology, epidemiology and allergic disease want to know why up to 20 percent of black people have asthma. The disease afflicts 20 million Americans, causes difficultly breathing, wheezing and tightness in the chest and can lead to hospitalization and death.

What’s different about this study from all the rest?

  •  About $9.5 million in funding comes from the National Heart, Lung and Blood Institute, part of the National Institutes of Health.
  • The study results will be publicly available though a national database maintained by the National Library of Medicine, an NIH member.  Usually, research studies are NOT available in a public format.
  • The study of 500 asthmatics and 500 non-asthmatics from 19 U.S., Caribbean, South American and Western African academic researcher centers aims to identify genetic variations that may be associated with elevated disease risk.  The important point here is that black people have different genetics for asthma depending on where you live or grew up.  The more you know the less you know!

How does all of the “genetic research” improve asthma care?  Here’s a video that explains an exciting potential for genetic research—>

#asthma, #black-people, #caribbean, #johns-hopkins, #national-heart-lung-and-blood-institute, #national-institutes-of-health, #united-states, #united-states-national-library-of-medicine

New Year’s Resolution–Who Should start Controller Meds?

New Year’s resolution!

I don’t like New Year’s Resolutions–if I don’t do something everyday, how is a resolution going to change my priority?  Behold…I bring you good tidings of great joy…taking regular PREVENTATIVE medication works the same way! 

So what’s the issue at hand?  Patients with asthma often want to stop preventive medication for the cough & wheeze.  I often hear…I don’t need it, only to suffer from an asthma attack with their next cold.  What are some useful strategies to improve asthma care in this regard?

 From the American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition: Abstract 14793. Presented October 14, 2011: 

American Academy of Pediatrics

  • Pediatricians strongly support the recommendation that emergency department (ED) physicians start asthma controller medications during an acute visit to the ED, according to research presented here at the American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition.
  • Why in the emergency room?  It’s the best time to have that one-on-one discussion with asthma patients.  You have their attention.

National asthma guidelines recommend that ED physicians consider initiating long-term controller medications when children present with an acute asthma attack. We all (I mean physicians) follow the guidelines, right?  Think again!

  • Many ED doctors are reluctant to do so, lead author Esther Maria Sampayo, MD, MPH, from the University of Pennsylvania School of Medicine, Philadelphia, said in an oral abstract session.
  • “One AAP study noted that less than 20% of ED doctors actually do this,” Dr. Sampayo told Medscape Medical News. “When you ask them why, they say it’s not their role to be the pediatrician and they shouldn’t be providing long-term management.”

If you don’t know the answer….then let’s find out.  The researchers did a cross-sectional mail survey of a randomly selected national sample of pediatricians involved in providing primary care from the AAP.

  • Of the 527 pediatricians who responded to the survey, 83% reported that they feel it is appropriate for the ED physician to initiate controller medications.
  • Just 23% of pediatricians reported that their patients “almost always” follow-up within 1 month after an ED visit. Makes you wonder what else gets “missed!”
  • Half (51%) of those surveyed believe that having ED physicians prescribe controller meds in the ED will encourage patients to follow-up. 
  • The survey also asked the pediatricians what they consider to be the benefits of having ED physicians initiate asthma controller medications. Most (85%) feel that it is a “teachable moment” and represents an important opportunity to capture patients who are poorly controlled.  Strike it while the iron is hot!

    Strike When the Iron is Hot!

Noah Kondamudi, MD, an asthma specialist in the Pediatric Emergency Department of the University of Medicine & Dentistry of New Jersey in Newark, said that in his experience, more and more ED doctors are prescribing asthma controller medications when children present with acute asthma.

Here in Oklahoma, no data is available on prescribing habits of emergency room physicians for asthma controller meds or the opinion of local pediatricians.  Do I hear a study that needs to be done?

“In general, emergency room doctors would not want to add to or change the primary care doctor’s chronic disease plan. However, more and more data are showing that many asthmatic children are not on controller medication, so initiating controller therapy should make a big difference,” he said.

My thanks to Fran Lowry who is a freelance writer for Medscape.  She has disclosed no relevant financial relationships.

#american-academy-of-pediatrics, #asthma, #emergency-department, #pediatric, #pharmaceutical-drug, #physician, #united-states, #university-of-pennsylvania-school-of-medicine

Too Good to Be True

Here’s a holiday tale that happens over and over again.  You’re an animal lover. You’re a college student and  get to come home for Thanksgiving to see your family and your cat! Cats have been a part of your life since age 5,  but in the past six months, what were mild allergy symptoms have gotten worse, causing sneezing, itchy, puffy eyes, and hives. Allergy tests have proven what her family suspected.  Oops!

 Life’s sweetest pleasures — a glass of wine, a beautifully scented room, the unconditional love of a pet — can sometimes set off fits of sneezing, coughing, hives and even serious asthma attacks.  I’m allergic to my three best friends!

An estimated 40 million to 50 million Americans suffer from asthma or other allergic diseases, and the incidence is increasing. Asthma rates alone have more than tripled in 25 years, now affecting more than 22 million people.  Why?

Theories include not only allergy, but irritants such as air pollutants, dietary changes and changes in lifestyle. Genes also are a factor, and people who have allergies are also more sensitive to irritants.  So what are some of these irritants that you can’t treat with allergy shots?

•Air fresheners and scented candles: Sometimes, the irritating trigger is right under your nose.  But don’t listen to just me.  Atlanta allergist Stanley Fineman, president-elect of the American College of Allergy, Asthma, and Immunology says, “I’ve been seeing more and more adults who are having problems with air fresheners–they’re coming in with all kinds of symptoms,” from sneezing and congestion to headache, coughing, fatigue and asthma.

Candles and air fresheners may emit volatile organic compounds, or VOCs, such as formaldehyde, petroleum distillates, limonene and other substances that increase asthma risk in children and can trigger eye and respiratory irritation and other health problems.

Candles burning

Treatment plans might include medication, changes in home décor or other avoidance strategies, but it starts with being aware. “People with asthma or respiratory sensitivity need to take precautions,” Fineman says, and doctors “may not have air fresheners on their radar screen. It’s helpful if we start thinking about that as another potential problem.”  Keep in mind, however, that allergy shots DON’T work for irritants such as odors.

•Alcoholic beverages:Reactions to wine or other alcohol-containing drinks are rare, but symptoms can range from rash to severe asthma attacks, says allergist Sami Bahna,

Sami Bahna

chief of allergy and immunology at Louisiana State University Medical School in Shreveport.

Potential allergens that occur naturally in beer and wine include hops, barley, ethanol, grapes, tryptamine, tyramine, wheat and histamine, and there may be added ingredients such as egg whites or sulfites, he says. “About a third of asthmatics can have difficulty with alcohol,” possibly in reaction to sulfites or other preservatives, he says.

Sweet

In some cases, a mild allergy to a wine ingredient pairs up with a mild allergy to something in food, such as cheese, and the combination can cause an allergic reaction.

•Pets: More than 90% of homes have “measurable dog and cat allergens,” even those that don’t have a resident pet, says  allergist Dana Wallace, president of the American College of Allergy, Asthma, and Immunology.

Animal dander, particularly cat dander, is “light and airborne for a long time.” People track it from their homes into stores, schools and homes of friends.

She advises patients to find new homes for the pets, but “in 30 years of practice, I can count on one hand the number who have willingly given up a pet.” Because it’s almost impossible to avoid pet dander anyway, she says, allergy shots are usually recommended to help patients tolerate exposure.

Patients are often willing to keep cats out of the bedroom, but “I refuse to get rid of them,” many patients say. “They’re definitely a part of the family.”

Pick Your Pet!

So what about you?  Are you willing to give up the holiday scents, a good glass of wine, or indoor pets just for the sake of allergy?

#air-freshener, #allergy, #asthma, #atlanta, #irritation, #louisiana-state-university-school-of-medicine, #united-states, #volatile-organic-compound

Can you learn about allergy from Sesame Street? No way!

The following video clip is worth your 6 minutes.  Enjoy.  Sesame Street explains .

#arts, #childrens, #elmo, #grover, #programs, #sesamestreet, #television, #united-states

The More Ya Know, the Less Ya Know!

I have just returned from the Annual Meeting of the American College of Allergy, Asthma, and Immunology held in Boston from Nov 3-8.  Sure the meeting was good, but the food was even better.  Consider the oldest “active” restaurant in America, Union Oyster House–the stew was delightful and if you’re bored with allergies, peruse the menu on-line and dream of dining with JFK (he has a booth in his name there). 

On to what’s new in allergy & asthma….

My, how things have changed!

Environmental Tobacco Smoke

Smoking bans in Tulsa have stirred some vigorous debate this year (see link).  Most importantly, do they work? Information presented last week would suggest a resounding YES!  In the U.S. more than 200,000 asthma admissions per year are attributed to Environmental Tobacco Smoke (ETS). Smoking bans can prevent this complication!  The Scottish health system has the database to measure the effects of a community-wide smoking ban and their intervention was associated with an 18% reduction in hospital admissions for asthma (NEJM 2010). Wow

If you have to smoke inside, HEPA filters reduced asthma visits in 6-12-year-old children by 18%.

VCD–Vocal Cord Dysfunction

I have a post on this blog describing VCD or paradoxical vocal cord motion.  Our terminology is now changing and instead of VCD, I like the term” irritable larnyx syndrome (WILS).”  The vocal cords are “housed” in the larynx and many structures and muscles have to work correctly in order for the vocal cords to allow air in and out of the lungs. This implies that multiple triggers will cause an attack and patients with difficult asthma may have a laryngeal dysfunction not just VCD. If you don’t believe me, look at this study.  World-wide recognition (AJRCCM, a study from Australia).

Tiotropium–alias Spiriva

Way too many choices in the treatment of asthma!  Why would you consider Tiotropium or Spiriva for asthma?

Picture says 1,000 words!

1.  Tiotropium works as step-up therapy in adult asthma.  Some patients just can’t tolerate albuterol or Xopenex™ because of tremor and other side effects.  Now you have an alternative: There were similar improvements in lung function and symptom-free days with Spiriva as adding long acting bronchodilator (NEJM 2011).

2.  Tiotropium does fit into the Asthma Guidelines (2007) and works better than increasing the dose of inhaled steroids (yea, less steroids) and is equal to salmeterol (Serevent).

3.  This report is from England, so BEWARE!  The Respimat inhaler isn’t used in the United States and should you read about this study, it doesn’t apply to patients in the US.  (Recent BMJ meta-analysis showed increased cardiovascular mortality with that formulation in COPD) (BMJ, 2011).Anti IL-13 (lebrikuzumab)–Did you say leprechaun?

There is one take home message with the use of lebrikuzumab:

1.  Personalized medicine is here!  In this study, patients that improved with anti IL-13 also had elevated levels of periostin in blood tests. Periostin is a marker of airway remodelling and gives us a clue as to why and how IL-13 contributes to asthma.  Lebrikizumab improved FEV1, but there was no improvement in symptoms or medication use (NEJM 2011).

Antibiotics

This comes from the literature review at the College meeting—1 of every 6 children with asthma seen the ED are prescribed antibiotics. Don’t you think this is high for a “practice” that is supposed to be very selective in who gets antibiotics?  Generally, antibiotics are not helpful in asthma anyway. More than 2 courses of antibiotics for cough in a 6-month time frame should warrant consideration of asthma as a cause (Pediatrics, 2011).

Mold allergy

In a study in Arizona, Fernandez et al. showed skin testing to Alternaria to be surprisingly accurate.  Ninety-six percent of patients with a positive skin test to this mold had a positive bronchial provocation test with Alternaria. In Arizona, Alternaria has surpassed dust mite as number one allergen in asthma (due to dry climate).  I wonder what results would be in Oklahoma?  Here’s what alternaria looks like: 

Alternaria under a microscope

Alternaria in real life

Immunotherapy

Come on now, do allergy shots REALLY work? Shots with dust mite allowed for inhaled steroid reduction by 50% in children with asthma vs. 30% in controls. Not bad! Do I have to take my medication with shots? Adding dust mite shots to pharmacologic treatment was an effective and safe strategy to reduce corticosteroid doses while maintaining disease control in children with mite-induced allergic asthma (JACI 2011).

Asthma

Which inhaled steroid to use?  Does it matter?  QVAR™ & Alvesco™ have said for quite some time that small particles penetrate the airways of an asthmatic better than the competition.  They may be right– small particle size inhaled steroids may allow for equal efficacy (benefit) with 1/2 to 1/3 the dose of a larger size of same steroid. Marketing isn’t bad, sometimes it’s just delayed results.

SABA update: Levalbuterol (Xopenex™) may not have any real-life advantages over albuterol. Even in the Xopenex™ package insert, there is  mention that there was no difference in heart rate or tremor.  In patients who swear by Xopenex™, there’s no reason to change, just start out with cheaper albuterol. 

Antihistamines for asthma?

Many patients take antihistamines every day like vitamins.  They feel better if an antihistamine is “on-board.”  Once again, learn from your patient….they will often give you clues to what medications work.  Symptom scores in asthma patients show comparable improvement when given desloratadine (antihistamine) compared to montelukast. Use of antihistamine may prevent the development of asthma in some predisposed children.  Well I’ll be….

Grandpa can’t breathe!

Asthma in the elderly

The majority of asthma deaths are in patients older than 65.

Asthma in adults/elderly is still predominantly an atopic disease. This means, it’s still due to allergy.  Don’t forget to test your older population.  In a University of Michigan study, 77% of adult asthma patients were skin test positive.

Depression is definitely underdiagnosed in our loved ones who have retired (ie, grandma & grandpa).  Why? They should have a carefree life during retirement, but they don’t. Depression is a significant factor for poor asthma quality of life in the elderly. You are 10x more likely to suffer from psychological dysfunction if you have more than 3 exacerbation of asthma in a single year. 

Just goes to show you that allergic respiratory disease is a very complicated condition and every year I’m challenged with new treatments!  I can’t ask for anything more.

#allergy, #alternaria, #american-college-of-allergy-asthma-immunology, #asthma, #bleeding, #dyspnea, #house-dust-mite, #immunology, #pediatric, #respiratory-disorders, #tiotropium, #union-oyster-house, #united-states, #vocal-cord-dysfunction, #wheeze

What do docs really do?

Most patients never know what doctors do when they’re NOT in the office.  One of those activities is attending national meetings in our chosen specialty.  For me, the American College of Allergy, Asthma, and Immunology is a yearly highlight.  You ask why?  Who wouldn’t want to see a distinguished doctor dress up and discuss hives?  Seriously, the ACAAI in Boston was a great opportunity to network and stay up to date on changing treatments for allergy & asthma!  It’s posted here.

Attendees of the ACAAI Annual Meeting voted Dr. David Khan winner of “The Great Chronic Idiopathic Urticaria Raft

What we do at Allergy meetings!

Debate: After Antihistamines, What’s Best for Next In-Line Treatment” based on his discussion of Hydroxychloroquine/dapsone.

#allergy, #american-college-of-allergy, #american-college-of-allergy-asthma-immunology, #asthma, #boston, #histamine-antagonist, #immunology, #united-states