New Biomarkers for Asthma on the Horizon

A biomarker is any measurable substance used to measure the state or presence of a disease.  A typical source for such a test might be a patient's blood or urine.  For asthma, markers of disease are being measured in exhaled breath condensate, which is the air you breathe out into a specialized collection device.  One known biomarker in asthma is exhaled nitric oxide, which can easily be measured in the doctor's office.  Other markers are being researched for use in the future. Dr. Susarla

Asymmetric Dimethylarginine in Exhaled Breath Condensate and Serum of Children With Asthma

Background:  Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor and uncoupler of nitric oxide synthase. By promoting the formation of peroxynitrite, ADMA is believed to contribute to several aspects of asthma pathogenesis (ie, airway inflammation, oxidative stress, bronchial hyperresponsiveness, and collagen deposition). The aim of the present study was to compare this mediator in healthy children and children with asthma using the completely noninvasive exhaled breath condensate (EBC) technique.

Methods:  We recruited 77 children with asthma (5-16 years of age) and 65 healthy children (5-15 years of age) who underwent EBC collection and spirometry. Serum ADMA levels and fractional exhaled nitric oxide levels were measured on the same day in a subgroup of children with asthma. EBC was collected using the Turbo-Deccs (Medivac). ADMA levels were measured using the ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) technique.

Results:  ADMA could be detected in the EBC of 71 subjects with asthma and 64 healthy subjects. ADMA levels in the EBC of children with asthma were significantly higher than in the healthy control subjects (median, 0.12 [interquartile range, 0.05-0.3] vs 0.07 [0.05-0.12]; P = .017), whereas no difference emerged between the children with asthma who were or were not receiving inhaled steroid treatment. No correlation was found between serum and EBC ADMA levels (P > .5).

Conclusions:  We measured ADMA in EBC by UPLC-MS/MS, a reference analytical technique. Higher ADMA levels were found in children with asthma, supporting a role for this mediator in asthma pathogenesis. This oxidative stress-related mediator also seems to be scarcely affected by steroid therapy. We speculate that ADMA might be a target for new therapeutic strategies designed to control oxidative stress in asthma.

Read abstract here.

Houston Area Seizure Action Plans for Children With Epilepsy

Make sure your child has an action plan...please contact me with a link if I missed your school. 

As a child neurologist / specialist in epilepsy, I fill out may of these forms.  Schools should be aware and prepared. JR

Selected Houston Area Seizure ACTION Plans for Schools

Houston ISD Seizure and Asthma action Plans

Katy ISD

• Seizure action Plan  http://www.katyisd.org/healthservices/Seizures/Seizure%20Action%20Plan%20.pdf
• Parent Questionnaire  http://www.katyisd.org/healthservices/Seizures/Parent%20Questionnaire%20-%20Seizures.pdf

Fort Bend ISD ( Sugar Land, Stafford ) Seizure, Asthma and Allergy ACTION PLAN

Spring Branch ISD ACTION PLAN for seizures, asthma, allergies & Diabetes

Conroe ISD ( The Woodlands)  Seizure information form 

Lamar Consolidated ISD ( Richmond Rosenberg Fulshear Pleak Greatwood Weston Lakes Simonton ) ACTION PLAN

Generic Forms from the EPILEPSY FOUNDATION

Why might this be? Children with allergies and asthma are known to have elevated risk of sleep disturbance, which could manifest with snoring in those with allergies, increased cough and respiratory symptoms during sleep for poorly controlled asthma. And finally, poor sleep quality can lead to symptoms of ADHD. Dr. Susarla

Children With Allergy, Asthma May Be at Higher Risk for ADHD

 The number of children being diagnosed with attention-deficit disorder (ADHD), allergy and asthma is increasing in the United States. And according to a new study, there might be a link between the growth of these three conditions.

The study, published in the August issue of Annals of Allergy, Asthma & Immunology, the scientific journal of the American College of Allergy, Asthma and Immunology (ACAAI), found there is an increased risk of ADHD in boys that have a history of allergy or asthma.

"ADHD, a chronic mental health disorder, is most commonly found in males, while asthma is also more common in young boys than girls," said Eelko Hak, lead study author. "We found there is an increased risk of ADHD in boys with a history of asthma and an even stronger risk associated with milk intolerance."

Researchers in the Netherlands and Boston studied 884 boys with ADHD and 3,536 boys without the disorder. Of the children with ADHD, 34 percent had asthma and 35 percent had an allergic disorder. The study suggests medications used to treat these conditions may be associated with an increased ADHD risk.

"Further research is needed to understand why there appears to be an increased risk of developing ADHD in children with allergy and asthma," said Gailen Marshall, MD, editor-in-chief of Annals of Allergy, Asthma & Immunology. "Medications for these conditions far outweigh the risks, and can be life-saving in some conditions. Treatment should not be stopped, unless advised by a board-certified allergist."

According to the ACAAI, allergy and asthma often run in families. If both parents have an allergy a child has a 75 percent chance of being allergic. If neither parent has allergy, the chance of a child developing an allergy is only 10 to 15 percent. Allergists also know allergies and asthma are linked. An estimated 60 to 80 percent of children with asthma also have an allergy. While the cause of ADHD is unknown, this disorder is also thought to run in families
.

Read article here.

There is undoubtedly a role for non-pharmacologic treatment of asthma and other kinds of respiratory disorders.  While they may not replace medication per se, a well conditioned, exercised lung probably manages inflammation and other forms of impairment better than an under utilized, poorly conditioned lung. Dr. Susarla

Really? Breathing Exercises Can Relieve Asthma

THE FACTS

Breathing exercises are among the most popular alternative therapies for asthmatics. But do they work?

According to a recent report by the Agency for Healthcare Research and Quality, the answer depends on the technique. Some appear effective in reducing asthma severity, but there is little evidence to support others.

In the exhaustive, 219-page report, researchers examined 22 randomized studies of breathing techniques. Among the most common are hyperventilation-reduction techniques like the Buteyko method, which instructs asthmatics to breathe shallowly and slowly through the nose when short of breath. The report also looked at yoga breathing exercises and so-called inspiratory-muscle training, which involves exercises and devices that make inhaling more difficult in order to strengthen muscles.

The researchers found the most robust body of evidence supported hyperventilation-reduction breathing techniques, which achieved “medium to large improvements in asthma symptoms and reductions in reliever medication use of approximately 1.5 to 2.5 puffs per day.”

Looking at inspiratory training approaches, the researchers could not find enough credible research to draw any firm conclusions. They did find some evidence for yoga exercises, which typically require deep breaths — usually through the nose — with extended exhalation. But most of the evidence came from studies in India, where yoga exercises are more intensive and frequent than in the United States.

Still, the authors said, “Patients with asthma who are students of yoga and willing to undertake intensive training may find benefits of asthma-targeted practice with a trained yoga practitioner.”

THE BOTTOM LINE

Breathing exercises may help relieve asthma, though the efficacy varies.

Read article here.

Effects of Exercise Training on Airway Hyperreactivity in Asthma: A Systematic Review and Meta-Analysis.

Abstract

BACKGROUND:

Although physical exercise is recommended for asthmatics, evidence on the effects of exercise on clinical key factors is still missing.

OBJECTIVES:

We performed a systematic review and meta-analysis to determine the effect of exercise training (EXT) on quality of life (QoL), bronchial hyperresponsiveness (BHR), exercise-induced bronchoconstriction (EIB), lung function and exercise capacity, plus the factors affecting changes in QoL and exercise capacity in asthmatics after a period of EXT.

DATA SOURCES:

A computerized search was conducted in MEDLINE, EMBASE, and CINAHL (last search on 15 November 2012), without language restriction, and references of original studies and reviews were searched for further relevant studies.

STUDY SELECTION:

Two independent investigators screened full-text studies with asthmatic subjects undertaking EXT (defined as training for ≥7 days, ≥2 times per week, ≥5 training sessions in total) that assessed at least one of the following outcomes: QoL, airway hyperreactivity, forced expiratory volume in one second (FEV1), peak expiratory flow (PEF), inflammatory parameters, exercise capacity, or exercise endurance. Potentially relevant studies were excluded if only respiratory muscle training, breathing exercises or yoga was performed, if asthmatic subjects with co-morbidities were investigated, if only data of mixed patient groups without separate results for asthmatics were presented, if training regimens were not sufficiently specified, if no numerical outcome data were presented, and if new long-term medication was introduced in addition to physical training. Of 500 potentially relevant articles, 13.4 % (67 studies including 2,059 subjects) met the eligibility criteria and were included for further analyses.

STUDY APPRAISAL AND SYNTHESIS METHODS:

Data extraction and risk of bias assessment was performed according to the Cochrane Handbook for Systematic Reviews of Interventions. A meta-analysis of all randomized controlled trials (RCTs) was performed to determine the effect of EXT on asthma symptoms, BHR, EIB, FEV1, exercise capacity and exercise endurance compared with control training. In addition, relative pre/post changes were analysed in all RCTs and controlled trials. Finally, multiple linear regression models were used to identify effects of relative changes in airway hyperreactivity (BHR or EIB), lung function (FEV1 or PEF) and training hours on QoL and exercise performance.

RESULTS:

In a total of 17 studies including 599 subjects, meta-analyses showed a significant improvement in days without asthma symptoms, FEV1and exercise capacity while BHR only tended to improve. The analysis of relative within-group changes after EXT showed, however, significant improvements in QoL (17 %), BHR (53 %), EIB (9 %), and FEV1 (3 %) compared with control conditions. Multiple linear regression models revealed that changes in airway hyperreactivity and lung function significantly contributed to the change in QoL, while mainly the changes in airway hyperreactivity contributed to the change in exercise capacity.

CONCLUSION:

EXT was shown to improve asthma symptoms, QoL, exercise capacity, BHR, EIB, and FEV1 in asthmatics and improvements in BHR explained part of the improvement in QoL and exercise capacity. Thus, physical activity should be recommended as a supplementary therapy to medication. However, more well controlled studies should be performed assessing the relationship of physical activity, QoL, airway hyperreactivity, lung function and especially airway inflammation as well as medication intake.

Read article here.

Genetic Test Could Predict Lasting Asthma Symptoms

Asthma for many, is certainly a combination of genetic risk and environmental exposure.  Tests may be available in the future to help identify risk.  Dr. Susarla

Genetic Test Could Predict Which Kids Will Have Lasting Asthma Symptoms

Half of children with asthma will continue to suffer from the respiratory disorder as adults, and a new genetic test could reveal who remains at risk past childhood.

About one in 11 children suffers from asthma, according to the Centers for Disease Control (CDC), and although half will eventually grow out of the condition, a recent CDC survey found that medical costs of asthma and its complications add up to about $56 billion each year. Improved treatment of those most likely to live with their condition longer term, say experts, could help to lower some of these costs, which include treating complications and mismanaged symptoms.

Researchers report in the journal Lancet Respiratory Medicine that a new genetic test may be able to predict a child’s risk of having asthma into adulthood, and therefore help doctors figure out which children might need more intensive care in childhood to potentially lower their risk of longer term symptoms.

The new study piggy backs on so-called genome-wide association (GWAS) studies, which compare those affected by asthma to those who are not to isolate specific genetic markers that could be associated with the disease. In the 40-year long study, Duke University researchers developed a genetic risk score that was based on 15 variants gleaned from previous GWAS, and looked at how these scores matched up to physical symptoms of asthma over time among 880 participants. The genetic score reflected only individual participant’s asthma risk, independent of family history.

The kids with higher scores, which meant they were more likely to possess more of the genetic markers linked to asthma, were also more likely to have asthma symptoms as adults, based on a 38 year follow-up. Those with the higher genetic risk also tended to miss school or work or be hospitalized for their symptoms more often than those with lower genetic scores.

Family history of asthma, the researchers say, did not appear to correlate with a higher genetic risk of the disease; many of the participants with high genetic risk had no family history of asthma, and conversely, people with a strong family history of the disease showed low genetic risk. That suggests that many of the cases were caused by environmental factors such as exposure to pollution or other irritants that have been linked to respiratory problems.

That means that doctors may need to expand the criteria they use to assess asthma risk to include measures such as genetic factors, which may be more predictive of future disease than family history. “What we are discovering in GWAS and doing molecular studies of asthma, is giving us new information over and above the old fashioned way we used to evaluate the genetic risk for asthma and still are in the clinic, which is to take family histories,” says study author Dan Belsky, a postdoctoral Fellow at Duke University. “I think that we are seeing more and more genomic medicine as time goes on. It is really coming into play in cancer medicine. It is not yet there in the treatment of asthma, but I think it will be coming. This study shows some of what may be possible.”

Belsky says scientists are far from knowing which genetic factors are directly responsible for causing asthma, but GWAS are a first step toward narrowing down the field of likely candidates. Most experts believe that for conditions such as asthma, multiple genes may contribute to the disease’s symptoms, so panels such as the one discovered in the current study could help to triage patients and ultimately guide them toward the most effective treatments — both in childhood and in adulthood.

Read article here.

Take your child's word for it on asthma, study finds

Many parents may be surprised by the subtlety of their child's asthma symptoms.  This frequently leads to underestimation of asthma severity.  Dr. Susarla

Take your child's word for it on asthma, study finds

SAN ANTONIO -- Children's perceptions of living with asthma may differ significantly from their caregivers' perceptions, which means both should be interviewed when they visit the doctor's office, a new study from UT Kids San Antonio and the Center for Airway Inflammation Research (cAIR) shows.

The study analyzed the agreement between 79 children and their caregivers on health-related quality-of-life questionnaires. The children ranged in age from 5 to 17. Fifty-three were classified as having acute asthma and 26 had refractory, or treatment-resistant, asthma.

Include children

"The take-home message is that children need to be included in the communication process with health care providers, and physicians need to elicit the child's perspective on their illness, health status, asthma symptoms and what is being done to treat their illness," said senior author Pamela Wood, M.D., Distinguished Teaching Professor of pediatrics in the School of Medicine at The University of Texas Health Science Center at San Antonio.

UT Kids is the clinical practice of the Department of Pediatrics. cAIR is a newly established research center at the Health Science Center's South Texas Research Facility that focuses on controlling and preventing acute and chronic airway diseases. The director is Joel Baseman, Ph.D.

Encouragement needed

Study lead author Margaret Burks, M.D., a 2013 graduate of the School of Medicine who is now an intern at Vanderbilt University, said children should be empowered to take control of their asthma. "Encouraging an environment where children can talk freely with their caregiver is important, and can start with allowing the child to participate in the office visit," Dr. Burks said. "It is important that children feel that their response to their disease is valued, not only by their physician but by their caregiver, as well."

Children were asked to rate their own limitations on activity, while caregivers were asked to rate the effect that the children's limitations had on family activities. "Overall, children viewed themselves as less impaired, in comparison to how caregivers viewed the limitations that the asthma placed on the family," Dr. Wood said.

Overcome barriers

Parents may not want to acknowledge a lack of communication when they go to a doctor's office. "I think there is often a concern in the minds of caregivers about how they appear to the physician," Dr. Burks said. "Caregivers may not want to seem out of touch with their child's day-to-day health, and, in such fear, they may dominate the conversation at the office visit. Our study demonstrates that it is helpful to gain insight from both the caregiver and the child."

Describing life with asthma to a health care provider can be an inexact science, to be sure. "There is no gold standard," Dr. Wood said. "We can't use a thermometer to measure quality of life."

Read article here.

Dealing with a new asthma diagnosis

A move to the gulf coast followed by new respiratory symptoms is a common theme in my practice.  Getting proactive by consulting a pediatric pulmonologist can make coping with a new asthma diagnosis a lot easier.  Dr. Susarla

Asthma arrives with move to Florida

My son did not win a perfect attendance award at school last year.

Instead, he set a personal record for the most days spent at the pediatrician's office.

Since moving from Colorado to Florida six months ago, my 7-year-old son, Ryan, developed asthma. He did not have allergies or any respiratory problems before we moved, but once we got to Florida, everything changed.

I noticed that he was constantly sneezing and sniffling, and his eyes were red and itchy, especially after being outside. These symptoms were manageable with the help of an over-the-counter antihistamine, but it was the cough that was troublesome.

Every few weeks, Ryan would start coughing and it would get so bad that and we'd end up at the pediatrician's office. At first, the doctor prescribed an oral steroid to alleviate the symptoms. This worked, but eventually the cough came back. After several more trips to the pediatrician's office due to severe coughing and wheezing, she determined that Ryan had asthma, or a reactive airway.

Ryan's body was reacting to something it perceived as harmful, and the airways of his lungs became inflamed and constricted. Since Ryan grew up in Colorado, he had never been exposed to certain allergy triggers that are common in Florida.

Working with Ryan's doctor, we came up with an asthma plan. He now has two prescribed inhalers to help control his asthma. He uses one inhaler on a daily basis to prevent asthma symptoms, and another he uses before playing sports to help his breathing. The doctor also had Ryan allergy tested so we could discover what his allergic triggers were. It turns out that he is highly allergic to mold, oak, and certain grasses, all things which are not common in Colorado.

In doing research, I found one website that was particularly helpful and has a lot of great information, asthma.com. It has a "For Parents" tab that discusses triggers and how to minimize exposure, and even a guideline for when your child should stay home from school due to symptoms.

Since Ryan is 7, he's old enough to understand and learn about his condition, so I found two websites that have informative and interactive games for him to play. Ryan likes watching Arthur, and pbskids.org has the Buster Baxter, Lung Defender game. There is also lungtropolis.com, which has a game for kids and a separate, informative section for parents.

Finding out that your child has asthma can be scary, but working with your doctor and arming yourself with information can help ease that anxiety. My goal is that Ryan won't have to miss any school because of his asthma, and he can win a perfect attendance award this year.

Read article here.

Turmeric Component Can Prevent Lung Damage in Premature Babies

Perhaps another nod to medicine through better nutrition, curcumin is a known potent antioxidant found in turmeric.  Oxidative injury is thought toplay a major role in bronchopulmonary dysplasia, a chronic lung condition affecting premature infants. Dr Susarla

Turmeric Component Can Prevent Lung Damage in Premature Babies

• A component found in turmeric can prevent lung damage in premature babies, a new study says.
  Babies born before 37 weeks of gestational age are considered to be premature babies. Though most of the internal systems of an unborn baby develop by 32 weeks, according to health experts, lungs remain immature at eight month of pregnancy and take more time to fully develop.
  So when babies are born before completing their gestational age, their lungs are not  fully developed. They require ventilation support and oxygen therapy. However, the therapies have long been found to increase the risk of lung damage, a condition known as bronchopulmonary dysplasia (BPD).  The condition is often accompanied by fluid in lungs and scarring. According to the American Lung Association, between 5,000 and 10,000 babies are affected with BPD every year. 
  The study reported in the American Journal of Physiology, Lung Cellular and Molecular Physiology, found a component in turmeric, known as curcumin, effective in protecting babies against the risk of the lung damage (BPD) and hyperoxia- a condition that is caused by excess oxygen in the body.  Premature babies often suffer from this condition nearly 21 days after birth.  
  The findings are based on the experiments conducted by a team of researchers from Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center (LA BioMed), with the help of disease models.
  "This is the first study to find long-term benefits of using curcumin to protect lung function in premature infants," Virender K. Rehan, author of the study, said in a news release. "Curcumin is known to have potent antioxidant, anti-inflammatory and anti-microbial properties, making it a promising therapy for premature infants who require oxygen therapy after birth."
  Preterm birth is the leading cause of newborn deaths and the second leading cause of death among children aged below 5 in the world. In the U.S. more than half a million babies are born prematurely. Apart from BPD, premature babies are affected by a series of health problems, including apnea; respiratory distress syndrome; jaundice; anemia; problems related to intestines (Necrotizing enterocolitis -NEC) and infections, particularly to lungs, blood, brain and spinal cord.
  Read article here.

Evaluation & Treatment of Abnormal Facial Movements after Bells Palsy / Facial Nerve Palsy.

After Bell's Palsy  or Facial nerve palsy   Nerves can regrow into muscles that were not originally mapped  together.  Some people will have problems with activating individual muscles like they did before. 

I see patients who will wink and smile the same time or who will tear when they taste spicy food.

 Parents and physicians should note that this can be successfully treated. - JR

Disabil Rehabil. 2010;32(17):1414-8. doi: 10.3109/09638280903514697.

Evaluation and treatment of synkinesis with botulinum toxin following facial nerve palsy.

Toffola ED, Furini F, Redaelli C, Prestifilippo E, Bejor M.

Source

Department of Physical Medicine and Rehabilitation, University of Pavia, IRCCS Fondazione Policlinico S. Matteo, Pavia, Italy. elena.dallatoffola@unipv.it

Abstract

PURPOSE:

To assess the effect and efficacy of botulinum toxin type A (BTX-A) in reducing synkinesis in aberrant facial nerve regeneration (following facial paralysis).

METHOD:

A total of 55 sessions of BTX-A (Botox) infiltration were performed on 30 patients (23 female) with synkinesis after facial palsy. Each subject was injected with 2.5 units of BTX-A in each injection site (the sites were chosen on a case-by-case basis). The synkinetic muscles targeted include: orbicularis oculi, zygomaticus major, depressor labii inferioris, platysma, healthy frontalis and healthy corrugator supercilii. The patients were examined using the Sunnybrook Facial Grading System, both before the BTX-A treatment and after an average of 35 days.

RESULTS:

All 30 patients experienced improvement to the synkinesis after treatment. Total scores: median pre-BTX-A: 40; post 53 p = 0.004. Resting symmetry scores: mean pre-BTX-A -7.1; post: -3.5; median pre -5 [interquartile range (IQR) -10 to -5]; post: -5 (IQR -5 to 0); p = 0.0001. Symmetry of voluntary movement median pre-BTX-A: 56 post 60 p = 0.10. Synkinesis scores: median pre-BTX-A: -9 post -3 p < 0.0001. Mean duration of improvement was 4 months.

CONCLUSIONS:

BTX-A injection treatment was effective in reducing facial synkinesis, thus improving facial expression symmetry both at rest and in voluntary movements.

Obesity and Asthma: Study Finds a Link in the Genes

New evidence identifies a genetic link with allergic inflammation. Dr. Susarla.

Obesity and Asthma: Study Finds a Link in the Genes

July 18, 2013 — Genes linked to chronic inflammation in asthma may be more active in people who are obese, according to new research that uncovers several biological ties between obesity and asthma.

"Our findings point the way to the management of asthma in the obese through simple weight reduction," said first author Paresh Dandona, MD, PhD, SUNY Distinguished Professor and Chief of Endocrinology, Diabetes and Metabolism at the University at Buffalo.

The research appeared online June 26 in the journal Obesity and involved two related studies: A comparative study between obese people and people of normal weights; and an experiment that looked at how various biological indicators -- including the behavior of asthma-linked genes -- changed when morbidly obese patients received gastric bypass surgery.

In the comparative study, the scientists found that four genes associated with chronic inflammation in asthma were more active in obese and morbidly obese people, by more than 100 percent in some cases. The highest activity was found in the morbidly obese.

This increased gene expression matters because it can cause white blood cells called mononuclear cells to produce far greater amounts of inflammatory factors like interleukin 4, LIGHT and lymphotoxinβ receptor which contribute to allergic inflammation and other abnormalities in the bronchial passages in asthma.

The scientists also found higher concentrations of two asthma-related compounds in the plasma of obese and morbidly obese patients: MMP-9, which is associated with inflammation, and nitric oxide metabolites (NOM), which are an indicator of oxidative stress.

Following gastric bypass surgery in morbidly obese diabetic patients, MMP-9 and NOM levels dropped, along with the expression of six asthma-related genes including the key factors, interleukin 4, LIGHT, lymphotoxinβ and interleukin 33 in parallel with weight loss and improvements in the status of their diabetes.

"Ours is the first study to provide a mechanistic link between obesity and asthma through biological/immunological mechanisms," Dandona said. "There has been, until now, no biological, mechanistic explanation other than the fact that obesity may raise the diaphragm and thus reduce lung volumes."

Read article here.