Pulmonary Health Hub

STANFORD, CALIF. – Therapy-resistant asthma usually isn’t.

Often it’s asthma that’s not really resistant to therapy, but a result of poor adherence to therapy, poor inhalation technique, or poor asthma control due to exposure to smoke or allergens.

And sometimes, it’s not even asthma. So, for a child with apparently severe asthma, first confirm the diagnosis and ensure that basic management strategies are in place and being followed, Dr. John D. Mark said at a pediatric update sponsored by Stanford University.

If you can improve the patient’s adherence to treatment, drug delivery, and exposure to environmental triggers, "you could fix nearly all ‘treatment-resistant asthma,’ " said Dr. Mark, a pediatric pulmonologist at Lucile Packard Children’s Hospital at Stanford.

He said he sees many patients referred for therapy-resistant asthma, but noted that there are not a lot of data on how to manage them.

Only 55 of 292 children with moderate to severe asthma, despite being prescribed at least 400 mcg/day of budesonide plus a long-acting beta-2 agonist, could be randomized after eligibility assessment in one treatment trial. Among the 237 who didn’t qualify, children either were nonadherent to treatment (38%) or were found to have mild or no asthma (25%) (J. Allergy Clin. Immunol. 2008;122:1138-44).

In a separate study of 780 patients aged 12-20 years with "severe asthma," the focus on basic asthma management during the run-in period of the trial improved symptoms so much that no clinically significant gains were achieved during the main part of the study by the use of exhaled nitric oxides as an indicator of control, even though this measure increased corticosteroid use (Lancet 2008;372:1065-72).

Another study found that 86% of 100 adults with chronic obstructive pulmonary disease or asthma were misusing their metered-dose inhaler (MDI) and 71% were misusing their Diskus dry powder inhaler (J. Gen. Intern. Med. 2011;26:635-42). A separate study of 127 children and adults found incorrect use of inhaler devices in 64% of MDI users and 26% of patients using the Rotahaler dry powder inhaler. Spacer devices seldom were used (J. Assoc. Physicians India 2005;53:681-4).

Dr. Mark said "therapy-resistant asthma" may fall into one of four categories:

• The wrong diagnosis. This is common, so do a diagnostic re-evaluation, he said.

• Asthma plus. Mild asthma exacerbated by one or more comorbidities is another common scenario. Some studies suggest that up to 15% of patients with severe or persistent asthma have dysfunctional breathing, such as vocal cord dysfunction. Rhinosinusitis, obesity, and food allergy can affect asthma control. Treating gastroesophageal reflux disorder usually does not improve asthma control much, Dr. Mark said.

• Difficult-to-treat asthma. This is a very common category in which poor treatment adherence or poor inhalation technique is the root of the problem. It often overlaps with the previous category.

• True resistance. Probably not common, this is severe therapy-resistant asthma that remains refractory to treatment even after dealing with reversible factors.

For diagnostic testing, start with lung function tests, he said. Spirometry is helpful, but the results may be normal even in cases of severe asthma. Longitudinal spirometry can be helpful, and bronchial responsiveness testing is helpful if the patient has persistent airflow limitation. Consider checking exhaled nitric oxide if that’s available and ordering complete lung function tests to evaluate lung volume and gas trapping. Look for markers of inflammation in induced sputum if the patient’s 1-second forced expiratory volume is more than 70% of predicted. An exercise challenge test also may be appropriate.

Perform an ear, nose, and throat or upper airway evaluation to look for vocal cord dysfunction. Assess tobacco smoke exposure by measuring cotinine in saliva or urine. If the patient has been prescribed theophylline, measure levels, Dr. Mark said.

Evaluate allergies by both skin prick testing and radioallergosorbent testing, looking for aeroallergens, fungi, and food allergens.

The role of bronchial challenge is not clear, and it can be dangerous if bronchial lability is present. There is no evidence to recommend routine high-resolution CT scans even in true severe, therapy-resistant pediatric asthma, he said.

For these tough cases, put on your Marcus Welby hat and make a home visit. "A home visit can be most rewarding," Dr. Mark said, because you can more accurately assess adherence to treatment, smoke exposure, allergens, and psychosocial factors such as acute and chronic stress, which are known to amplify the airway eosinophilic response to an allergen challenge.

A home visit helped solve the mystery of one 8-year-old boy with severe persistent asthma. Scans revealed no chronic sinusitis or bronchiectasis. But testing showed he was allergic to at least 32 substances, and a home inspection revealed mold throughout the house. Social services helped the family move to a new home, and Dr. Mark added itraconazole to the boy’s treatment regimen.

"You can figure it out," Dr. Mark said. "It took me around 3 years for this guy."

Dr. Mark reported having no relevant financial disclosures.

STANFORD, CALIF. – Therapy-resistant asthma usually isn’t.

Often it’s asthma that’s not really resistant to therapy, but a result of poor adherence to therapy, poor inhalation technique, or poor asthma control due to exposure to smoke or allergens.

And sometimes, it’s not even asthma. So, for a child with apparently severe asthma, first confirm the diagnosis and ensure that basic management strategies are in place and being followed, Dr. John D. Mark said at a pediatric update sponsored by Stanford University.

If you can improve the patient’s adherence to treatment, drug delivery, and exposure to environmental triggers, "you could fix nearly all ‘treatment-resistant asthma,’ " said Dr. Mark, a pediatric pulmonologist at Lucile Packard Children’s Hospital at Stanford.

He said he sees many patients referred for therapy-resistant asthma, but noted that there are not a lot of data on how to manage them.

Only 55 of 292 children with moderate to severe asthma, despite being prescribed at least 400 mcg/day of budesonide plus a long-acting beta-2 agonist, could be randomized after eligibility assessment in one treatment trial. Among the 237 who didn’t qualify, children either were nonadherent to treatment (38%) or were found to have mild or no asthma (25%) (J. Allergy Clin. Immunol. 2008;122:1138-44).

In a separate study of 780 patients aged 12-20 years with "severe asthma," the focus on basic asthma management during the run-in period of the trial improved symptoms so much that no clinically significant gains were achieved during the main part of the study by the use of exhaled nitric oxides as an indicator of control, even though this measure increased corticosteroid use (Lancet 2008;372:1065-72).

Another study found that 86% of 100 adults with chronic obstructive pulmonary disease or asthma were misusing their metered-dose inhaler (MDI) and 71% were misusing their Diskus dry powder inhaler (J. Gen. Intern. Med. 2011;26:635-42). A separate study of 127 children and adults found incorrect use of inhaler devices in 64% of MDI users and 26% of patients using the Rotahaler dry powder inhaler. Spacer devices seldom were used (J. Assoc. Physicians India 2005;53:681-4).

Dr. Mark said "therapy-resistant asthma" may fall into one of four categories:

• The wrong diagnosis. This is common, so do a diagnostic re-evaluation, he said.

• Asthma plus. Mild asthma exacerbated by one or more comorbidities is another common scenario. Some studies suggest that up to 15% of patients with severe or persistent asthma have dysfunctional breathing, such as vocal cord dysfunction. Rhinosinusitis, obesity, and food allergy can affect asthma control. Treating gastroesophageal reflux disorder usually does not improve asthma control much, Dr. Mark said.

• Difficult-to-treat asthma. This is a very common category in which poor treatment adherence or poor inhalation technique is the root of the problem. It often overlaps with the previous category.

• True resistance. Probably not common, this is severe therapy-resistant asthma that remains refractory to treatment even after dealing with reversible factors.

For diagnostic testing, start with lung function tests, he said. Spirometry is helpful, but the results may be normal even in cases of severe asthma. Longitudinal spirometry can be helpful, and bronchial responsiveness testing is helpful if the patient has persistent airflow limitation. Consider checking exhaled nitric oxide if that’s available and ordering complete lung function tests to evaluate lung volume and gas trapping. Look for markers of inflammation in induced sputum if the patient’s 1-second forced expiratory volume is more than 70% of predicted. An exercise challenge test also may be appropriate.

Perform an ear, nose, and throat or upper airway evaluation to look for vocal cord dysfunction. Assess tobacco smoke exposure by measuring cotinine in saliva or urine. If the patient has been prescribed theophylline, measure levels, Dr. Mark said.

Evaluate allergies by both skin prick testing and radioallergosorbent testing, looking for aeroallergens, fungi, and food allergens.

The role of bronchial challenge is not clear, and it can be dangerous if bronchial lability is present. There is no evidence to recommend routine high-resolution CT scans even in true severe, therapy-resistant pediatric asthma, he said.

For these tough cases, put on your Marcus Welby hat and make a home visit. "A home visit can be most rewarding," Dr. Mark said, because you can more accurately assess adherence to treatment, smoke exposure, allergens, and psychosocial factors such as acute and chronic stress, which are known to amplify the airway eosinophilic response to an allergen challenge.

A home visit helped solve the mystery of one 8-year-old boy with severe persistent asthma. Scans revealed no chronic sinusitis or bronchiectasis. But testing showed he was allergic to at least 32 substances, and a home inspection revealed mold throughout the house. Social services helped the family move to a new home, and Dr. Mark added itraconazole to the boy’s treatment regimen.

"You can figure it out," Dr. Mark said. "It took me around 3 years for this guy."

Dr. Mark reported having no relevant financial disclosures.

STANFORD, CALIF. – Therapy-resistant asthma usually isn’t.

Often it’s asthma that’s not really resistant to therapy, but a result of poor adherence to therapy, poor inhalation technique, or poor asthma control due to exposure to smoke or allergens.

And sometimes, it’s not even asthma. So, for a child with apparently severe asthma, first confirm the diagnosis and ensure that basic management strategies are in place and being followed, Dr. John D. Mark said at a pediatric update sponsored by Stanford University.

If you can improve the patient’s adherence to treatment, drug delivery, and exposure to environmental triggers, "you could fix nearly all ‘treatment-resistant asthma,’ " said Dr. Mark, a pediatric pulmonologist at Lucile Packard Children’s Hospital at Stanford.

He said he sees many patients referred for therapy-resistant asthma, but noted that there are not a lot of data on how to manage them.

Only 55 of 292 children with moderate to severe asthma, despite being prescribed at least 400 mcg/day of budesonide plus a long-acting beta-2 agonist, could be randomized after eligibility assessment in one treatment trial. Among the 237 who didn’t qualify, children either were nonadherent to treatment (38%) or were found to have mild or no asthma (25%) (J. Allergy Clin. Immunol. 2008;122:1138-44).

In a separate study of 780 patients aged 12-20 years with "severe asthma," the focus on basic asthma management during the run-in period of the trial improved symptoms so much that no clinically significant gains were achieved during the main part of the study by the use of exhaled nitric oxides as an indicator of control, even though this measure increased corticosteroid use (Lancet 2008;372:1065-72).

Another study found that 86% of 100 adults with chronic obstructive pulmonary disease or asthma were misusing their metered-dose inhaler (MDI) and 71% were misusing their Diskus dry powder inhaler (J. Gen. Intern. Med. 2011;26:635-42). A separate study of 127 children and adults found incorrect use of inhaler devices in 64% of MDI users and 26% of patients using the Rotahaler dry powder inhaler. Spacer devices seldom were used (J. Assoc. Physicians India 2005;53:681-4).

Dr. Mark said "therapy-resistant asthma" may fall into one of four categories:

• The wrong diagnosis. This is common, so do a diagnostic re-evaluation, he said.

• Asthma plus. Mild asthma exacerbated by one or more comorbidities is another common scenario. Some studies suggest that up to 15% of patients with severe or persistent asthma have dysfunctional breathing, such as vocal cord dysfunction. Rhinosinusitis, obesity, and food allergy can affect asthma control. Treating gastroesophageal reflux disorder usually does not improve asthma control much, Dr. Mark said.

• Difficult-to-treat asthma. This is a very common category in which poor treatment adherence or poor inhalation technique is the root of the problem. It often overlaps with the previous category.

• True resistance. Probably not common, this is severe therapy-resistant asthma that remains refractory to treatment even after dealing with reversible factors.

For diagnostic testing, start with lung function tests, he said. Spirometry is helpful, but the results may be normal even in cases of severe asthma. Longitudinal spirometry can be helpful, and bronchial responsiveness testing is helpful if the patient has persistent airflow limitation. Consider checking exhaled nitric oxide if that’s available and ordering complete lung function tests to evaluate lung volume and gas trapping. Look for markers of inflammation in induced sputum if the patient’s 1-second forced expiratory volume is more than 70% of predicted. An exercise challenge test also may be appropriate.

Perform an ear, nose, and throat or upper airway evaluation to look for vocal cord dysfunction. Assess tobacco smoke exposure by measuring cotinine in saliva or urine. If the patient has been prescribed theophylline, measure levels, Dr. Mark said.

Evaluate allergies by both skin prick testing and radioallergosorbent testing, looking for aeroallergens, fungi, and food allergens.

The role of bronchial challenge is not clear, and it can be dangerous if bronchial lability is present. There is no evidence to recommend routine high-resolution CT scans even in true severe, therapy-resistant pediatric asthma, he said.

For these tough cases, put on your Marcus Welby hat and make a home visit. "A home visit can be most rewarding," Dr. Mark said, because you can more accurately assess adherence to treatment, smoke exposure, allergens, and psychosocial factors such as acute and chronic stress, which are known to amplify the airway eosinophilic response to an allergen challenge.

A home visit helped solve the mystery of one 8-year-old boy with severe persistent asthma. Scans revealed no chronic sinusitis or bronchiectasis. But testing showed he was allergic to at least 32 substances, and a home inspection revealed mold throughout the house. Social services helped the family move to a new home, and Dr. Mark added itraconazole to the boy’s treatment regimen.

"You can figure it out," Dr. Mark said. "It took me around 3 years for this guy."

Dr. Mark reported having no relevant financial disclosures.

Withdrawing long-acting beta-agonist therapy worsened refractory asthma that had been controlled with a combination of LABAs and inhaled corticosteroids, according to a meta-analysis published online Aug. 27 in Archives of Internal Medicine.

The findings run counter to the Food and Drug Administration’s black-box warning that patients should reduce use of LABAs such as salmeterol or formoterol once they achieve asthma control.

Stopping LABAs after achieving asthma control was associated with reduced asthma control, increased symptom frequency, increased use of rescue bronchodilators, decreased asthma-related quality of life, and similar rates of adverse events and serious adverse events, compared with continuing LABAs in combination therapy, according to the meta-analysis’ authors, who focused on the only five randomized, controlled clinical trials (RCTs) to examine this issue.

"Thus, in contrast to FDA recommendations of stepping off LABA therapy [once] asthma is controlled, our analysis supports the continued use of LABAs to maintain asthma control," said Dr. Jan L. Brozek of the department of clinical epidemiology and biostatistics and medicine, McMaster University, Hamilton, Ont., and his associates (Arch. Intern. Med. 2012 [doi:10.1001/archinternmed.2012.3250]).

However, they noted that this conclusion is based on the pooled results of only five studies, all of which had substantial limitations.

"An interesting and important finding is the paucity of studies evaluating this issue," Dr. Brozek and his colleagues said.

The researchers undertook the meta-analysis because of the ongoing controversy over whether to withdraw or continue LABA therapy once asthma is adequately controlled, as the FDA recommends in a black-box warning for the drugs.

The five RCTs included in the meta-analysis were all sponsored by the manufacturers of the study drugs. Four were published in peer-reviewed journals, and one was a conference abstract. All the RCTs involved adolescents or adults with at least a 6-month history of mild to moderate asthma, but four of the five trials did not specify whether combined therapy with inhaled corticosteroids and LABAs had been required to control symptoms at enrollment.

Compared with continued combination therapy, LABA step-down therapy was associated with an average 0.24-point drop in Asthma Quality of Life Questionnaire scores for control of asthma, 9.2% fewer symptom-free days, and an average of 0.71 more puffs/day from a rescue bronchodilator.

Despite the meta-analysis results, the investigators cautioned that the duration of well-controlled asthma on combination therapy was shorter than the 3 months that are recommended to adequately judge the treatment effect.

In addition, the studies included only 1,342 patients: 660 who gradually withdrew from LABA therapy, and 682 who continued on it.

None of the RCTs reported emergency department visits, unscheduled office visits for asthma, days missed from work or school, costs, or complications associated with the corticosteroids, the authors said. All were of short duration, none provided information on treatment adherence, and some had high dropout rates.

Nevertheless, "our findings likely represent the current best evidence about stepping off LABA therapy in patients with asthma," the investigators asserted.

The pooled analysis showed "no statistically significant results for any of the reported asthma outcomes of interest showing a benefit from [the] LABA step-off approach, compared with continued use of the same dose of inhaled corticosteroids and LABA," Dr. Brozek and his associates said.

Discontinuing LABA therapy significantly reduced asthma control and asthma-related quality of life. It increased symptom frequency and the use of rescue bronchodilators, and raised the risk that subjects would withdraw from the studies because of lack of efficacy or loss of asthma control. It also increased the need for oral corticosteroids but not to a statistically significant degree.

"Because of the paucity of data, we were unable to assess the critical issue of ... whether LABA use had any effect on catastrophic asthma events," they added.

"There is clearly a need for more properly designed and executed randomized trials aimed at rectifying differences between asthma guideline recommendations and FDA safety concerns," the investigators concluded.

The meta-analysis was supported by McMaster University, the American Academy of Allergy, Asthma, and Immunology, and the American Thoracic Society. The researchers reported ties to Abbott, Asthmatix, Astra-Zeneca, Boehringer Ingelheim, Eumedics, Genentech, GlaxoSmithKline, Johnson & Johnson, Merck, Novartis, and Sanofi-Aventis.

Withdrawing long-acting beta-agonist therapy worsened refractory asthma that had been controlled with a combination of LABAs and inhaled corticosteroids, according to a meta-analysis published online Aug. 27 in Archives of Internal Medicine.

The findings run counter to the Food and Drug Administration’s black-box warning that patients should reduce use of LABAs such as salmeterol or formoterol once they achieve asthma control.

Stopping LABAs after achieving asthma control was associated with reduced asthma control, increased symptom frequency, increased use of rescue bronchodilators, decreased asthma-related quality of life, and similar rates of adverse events and serious adverse events, compared with continuing LABAs in combination therapy, according to the meta-analysis’ authors, who focused on the only five randomized, controlled clinical trials (RCTs) to examine this issue.

"Thus, in contrast to FDA recommendations of stepping off LABA therapy [once] asthma is controlled, our analysis supports the continued use of LABAs to maintain asthma control," said Dr. Jan L. Brozek of the department of clinical epidemiology and biostatistics and medicine, McMaster University, Hamilton, Ont., and his associates (Arch. Intern. Med. 2012 [doi:10.1001/archinternmed.2012.3250]).

However, they noted that this conclusion is based on the pooled results of only five studies, all of which had substantial limitations.

"An interesting and important finding is the paucity of studies evaluating this issue," Dr. Brozek and his colleagues said.

The researchers undertook the meta-analysis because of the ongoing controversy over whether to withdraw or continue LABA therapy once asthma is adequately controlled, as the FDA recommends in a black-box warning for the drugs.

The five RCTs included in the meta-analysis were all sponsored by the manufacturers of the study drugs. Four were published in peer-reviewed journals, and one was a conference abstract. All the RCTs involved adolescents or adults with at least a 6-month history of mild to moderate asthma, but four of the five trials did not specify whether combined therapy with inhaled corticosteroids and LABAs had been required to control symptoms at enrollment.

Compared with continued combination therapy, LABA step-down therapy was associated with an average 0.24-point drop in Asthma Quality of Life Questionnaire scores for control of asthma, 9.2% fewer symptom-free days, and an average of 0.71 more puffs/day from a rescue bronchodilator.

Despite the meta-analysis results, the investigators cautioned that the duration of well-controlled asthma on combination therapy was shorter than the 3 months that are recommended to adequately judge the treatment effect.

In addition, the studies included only 1,342 patients: 660 who gradually withdrew from LABA therapy, and 682 who continued on it.

None of the RCTs reported emergency department visits, unscheduled office visits for asthma, days missed from work or school, costs, or complications associated with the corticosteroids, the authors said. All were of short duration, none provided information on treatment adherence, and some had high dropout rates.

Nevertheless, "our findings likely represent the current best evidence about stepping off LABA therapy in patients with asthma," the investigators asserted.

The pooled analysis showed "no statistically significant results for any of the reported asthma outcomes of interest showing a benefit from [the] LABA step-off approach, compared with continued use of the same dose of inhaled corticosteroids and LABA," Dr. Brozek and his associates said.

Discontinuing LABA therapy significantly reduced asthma control and asthma-related quality of life. It increased symptom frequency and the use of rescue bronchodilators, and raised the risk that subjects would withdraw from the studies because of lack of efficacy or loss of asthma control. It also increased the need for oral corticosteroids but not to a statistically significant degree.

"Because of the paucity of data, we were unable to assess the critical issue of ... whether LABA use had any effect on catastrophic asthma events," they added.

"There is clearly a need for more properly designed and executed randomized trials aimed at rectifying differences between asthma guideline recommendations and FDA safety concerns," the investigators concluded.

The meta-analysis was supported by McMaster University, the American Academy of Allergy, Asthma, and Immunology, and the American Thoracic Society. The researchers reported ties to Abbott, Asthmatix, Astra-Zeneca, Boehringer Ingelheim, Eumedics, Genentech, GlaxoSmithKline, Johnson & Johnson, Merck, Novartis, and Sanofi-Aventis.

Withdrawing long-acting beta-agonist therapy worsened refractory asthma that had been controlled with a combination of LABAs and inhaled corticosteroids, according to a meta-analysis published online Aug. 27 in Archives of Internal Medicine.

The findings run counter to the Food and Drug Administration’s black-box warning that patients should reduce use of LABAs such as salmeterol or formoterol once they achieve asthma control.

Stopping LABAs after achieving asthma control was associated with reduced asthma control, increased symptom frequency, increased use of rescue bronchodilators, decreased asthma-related quality of life, and similar rates of adverse events and serious adverse events, compared with continuing LABAs in combination therapy, according to the meta-analysis’ authors, who focused on the only five randomized, controlled clinical trials (RCTs) to examine this issue.

"Thus, in contrast to FDA recommendations of stepping off LABA therapy [once] asthma is controlled, our analysis supports the continued use of LABAs to maintain asthma control," said Dr. Jan L. Brozek of the department of clinical epidemiology and biostatistics and medicine, McMaster University, Hamilton, Ont., and his associates (Arch. Intern. Med. 2012 [doi:10.1001/archinternmed.2012.3250]).

However, they noted that this conclusion is based on the pooled results of only five studies, all of which had substantial limitations.

"An interesting and important finding is the paucity of studies evaluating this issue," Dr. Brozek and his colleagues said.

The researchers undertook the meta-analysis because of the ongoing controversy over whether to withdraw or continue LABA therapy once asthma is adequately controlled, as the FDA recommends in a black-box warning for the drugs.

The five RCTs included in the meta-analysis were all sponsored by the manufacturers of the study drugs. Four were published in peer-reviewed journals, and one was a conference abstract. All the RCTs involved adolescents or adults with at least a 6-month history of mild to moderate asthma, but four of the five trials did not specify whether combined therapy with inhaled corticosteroids and LABAs had been required to control symptoms at enrollment.

Compared with continued combination therapy, LABA step-down therapy was associated with an average 0.24-point drop in Asthma Quality of Life Questionnaire scores for control of asthma, 9.2% fewer symptom-free days, and an average of 0.71 more puffs/day from a rescue bronchodilator.

Despite the meta-analysis results, the investigators cautioned that the duration of well-controlled asthma on combination therapy was shorter than the 3 months that are recommended to adequately judge the treatment effect.

In addition, the studies included only 1,342 patients: 660 who gradually withdrew from LABA therapy, and 682 who continued on it.

None of the RCTs reported emergency department visits, unscheduled office visits for asthma, days missed from work or school, costs, or complications associated with the corticosteroids, the authors said. All were of short duration, none provided information on treatment adherence, and some had high dropout rates.

Nevertheless, "our findings likely represent the current best evidence about stepping off LABA therapy in patients with asthma," the investigators asserted.

The pooled analysis showed "no statistically significant results for any of the reported asthma outcomes of interest showing a benefit from [the] LABA step-off approach, compared with continued use of the same dose of inhaled corticosteroids and LABA," Dr. Brozek and his associates said.

Discontinuing LABA therapy significantly reduced asthma control and asthma-related quality of life. It increased symptom frequency and the use of rescue bronchodilators, and raised the risk that subjects would withdraw from the studies because of lack of efficacy or loss of asthma control. It also increased the need for oral corticosteroids but not to a statistically significant degree.

"Because of the paucity of data, we were unable to assess the critical issue of ... whether LABA use had any effect on catastrophic asthma events," they added.

"There is clearly a need for more properly designed and executed randomized trials aimed at rectifying differences between asthma guideline recommendations and FDA safety concerns," the investigators concluded.

The meta-analysis was supported by McMaster University, the American Academy of Allergy, Asthma, and Immunology, and the American Thoracic Society. The researchers reported ties to Abbott, Asthmatix, Astra-Zeneca, Boehringer Ingelheim, Eumedics, Genentech, GlaxoSmithKline, Johnson & Johnson, Merck, Novartis, and Sanofi-Aventis.

ESTES PARK, COLO. – Look in the near future for widespread adoption of a more selective approach to getting chest radiographs after pneumonia.

Since 2000, the American Thoracic Society, the British Thoracic Society, and the Canadian Infectious Diseases Society along with the Canadian Thoracic Society have published guidelines for management of community-acquired pneumonia. The guidelines recommend a routine follow-up chest x-ray within a couple of months after the treatment of pneumonia. The main purpose, other than in the minority of patients with ongoing pneumonia-related symptoms, is to exclude an underlying lung cancer that may have predisposed to the pneumonia.

However, recent studies suggest that the diagnostic yield of these follow-up radiographs is too low to justify a recommendation for routine imaging. The contention is that only the subset of pneumonia patients who are at increased risk for lung cancer should be targeted for a follow-up chest x-ray. A more selective approach will save substantial health care dollars and reduce radiation exposure, according to Dr. Robert L. Keith, professor of medicine and a pulmonologist at the University of Colorado at Denver, Aurora, which sponsored this update in internal medicine.

He cited what he considers "a great study" by Canadian investigators who conducted a population-based study of 3,398 Edmonton patients who had been followed for 5 years after treatment of pneumonia. The incidence of diagnosis of new lung cancer was 1.1% at 90 days, 1.7% at 1 year, and 2.3% at 5 years, which the investigators deemed too low to provide a strong rationale for routine follow-up chest x-rays (Arch. Intern. Med. 2011;171:1193-8).

Only 40% of the patients had had a follow-up chest x-ray within 90 days, suggesting that the majority of Edmonton-area physicians were already skeptical about guideline-recommended routine postpneumonia radiography. The diagnostic yield of lung cancer achieved via the imaging studies was 2.5%.

A key study finding was that none of the 79 lung cancers that were diagnosed within 5 years following pneumonia occurred in patients younger than age 40 years at the time of their lung infection, and only five cases occurred in 40- to 49-year-olds. The investigators identified three independent risk factors associated with lung cancer within 5 years after an episode of pneumonia: age 50 years or more, with a relative risk of 19; male sex, with a 1.8-fold increased risk; and current smoking, with a relative risk of 1.7.

Dr. Keith predicted that most health care systems are going to endorse the lung cancer screening strategy that proved so successful in the landmark National Lung Screening Trial (N. Engl. J. Med. 2011;365:395-409). That study in more than 50,000 subjects showed that screening via low-dose helical chest CT reduced lung cancer mortality by 20%, compared with screening by chest x-ray in high-risk patients as defined mainly by their age and smoking history.

Based upon the results of this National Cancer Institute–sponsored study and other recent lung cancer screening studies, the National Comprehensive Cancer Network has recommended routine screening using low-dose helical CT for two high-risk groups: individuals aged 55-74 years with at least 30 pack-years of smoking who either are current smokers or who quit fewer than 15 years ago, and patients aged 50 or older with at least 20 pack-years of smoking and one additional risk factor. The additional risk factors are contact with radon, occupational exposure to asbestos or other carcinogens, a history of lung cancer in a first-degree relative, a personal history of any tobacco-related aerodigestive cancer, or chronic obstructive pulmonary disease.

Dr. Keith reported that he serves on the speakers bureaus for Boehringer Ingelheim and Pfizer.

ESTES PARK, COLO. – Look in the near future for widespread adoption of a more selective approach to getting chest radiographs after pneumonia.

Since 2000, the American Thoracic Society, the British Thoracic Society, and the Canadian Infectious Diseases Society along with the Canadian Thoracic Society have published guidelines for management of community-acquired pneumonia. The guidelines recommend a routine follow-up chest x-ray within a couple of months after the treatment of pneumonia. The main purpose, other than in the minority of patients with ongoing pneumonia-related symptoms, is to exclude an underlying lung cancer that may have predisposed to the pneumonia.

However, recent studies suggest that the diagnostic yield of these follow-up radiographs is too low to justify a recommendation for routine imaging. The contention is that only the subset of pneumonia patients who are at increased risk for lung cancer should be targeted for a follow-up chest x-ray. A more selective approach will save substantial health care dollars and reduce radiation exposure, according to Dr. Robert L. Keith, professor of medicine and a pulmonologist at the University of Colorado at Denver, Aurora, which sponsored this update in internal medicine.

He cited what he considers "a great study" by Canadian investigators who conducted a population-based study of 3,398 Edmonton patients who had been followed for 5 years after treatment of pneumonia. The incidence of diagnosis of new lung cancer was 1.1% at 90 days, 1.7% at 1 year, and 2.3% at 5 years, which the investigators deemed too low to provide a strong rationale for routine follow-up chest x-rays (Arch. Intern. Med. 2011;171:1193-8).

Only 40% of the patients had had a follow-up chest x-ray within 90 days, suggesting that the majority of Edmonton-area physicians were already skeptical about guideline-recommended routine postpneumonia radiography. The diagnostic yield of lung cancer achieved via the imaging studies was 2.5%.

A key study finding was that none of the 79 lung cancers that were diagnosed within 5 years following pneumonia occurred in patients younger than age 40 years at the time of their lung infection, and only five cases occurred in 40- to 49-year-olds. The investigators identified three independent risk factors associated with lung cancer within 5 years after an episode of pneumonia: age 50 years or more, with a relative risk of 19; male sex, with a 1.8-fold increased risk; and current smoking, with a relative risk of 1.7.

Dr. Keith predicted that most health care systems are going to endorse the lung cancer screening strategy that proved so successful in the landmark National Lung Screening Trial (N. Engl. J. Med. 2011;365:395-409). That study in more than 50,000 subjects showed that screening via low-dose helical chest CT reduced lung cancer mortality by 20%, compared with screening by chest x-ray in high-risk patients as defined mainly by their age and smoking history.

Based upon the results of this National Cancer Institute–sponsored study and other recent lung cancer screening studies, the National Comprehensive Cancer Network has recommended routine screening using low-dose helical CT for two high-risk groups: individuals aged 55-74 years with at least 30 pack-years of smoking who either are current smokers or who quit fewer than 15 years ago, and patients aged 50 or older with at least 20 pack-years of smoking and one additional risk factor. The additional risk factors are contact with radon, occupational exposure to asbestos or other carcinogens, a history of lung cancer in a first-degree relative, a personal history of any tobacco-related aerodigestive cancer, or chronic obstructive pulmonary disease.

Dr. Keith reported that he serves on the speakers bureaus for Boehringer Ingelheim and Pfizer.

ESTES PARK, COLO. – Look in the near future for widespread adoption of a more selective approach to getting chest radiographs after pneumonia.

Since 2000, the American Thoracic Society, the British Thoracic Society, and the Canadian Infectious Diseases Society along with the Canadian Thoracic Society have published guidelines for management of community-acquired pneumonia. The guidelines recommend a routine follow-up chest x-ray within a couple of months after the treatment of pneumonia. The main purpose, other than in the minority of patients with ongoing pneumonia-related symptoms, is to exclude an underlying lung cancer that may have predisposed to the pneumonia.

However, recent studies suggest that the diagnostic yield of these follow-up radiographs is too low to justify a recommendation for routine imaging. The contention is that only the subset of pneumonia patients who are at increased risk for lung cancer should be targeted for a follow-up chest x-ray. A more selective approach will save substantial health care dollars and reduce radiation exposure, according to Dr. Robert L. Keith, professor of medicine and a pulmonologist at the University of Colorado at Denver, Aurora, which sponsored this update in internal medicine.

He cited what he considers "a great study" by Canadian investigators who conducted a population-based study of 3,398 Edmonton patients who had been followed for 5 years after treatment of pneumonia. The incidence of diagnosis of new lung cancer was 1.1% at 90 days, 1.7% at 1 year, and 2.3% at 5 years, which the investigators deemed too low to provide a strong rationale for routine follow-up chest x-rays (Arch. Intern. Med. 2011;171:1193-8).

Only 40% of the patients had had a follow-up chest x-ray within 90 days, suggesting that the majority of Edmonton-area physicians were already skeptical about guideline-recommended routine postpneumonia radiography. The diagnostic yield of lung cancer achieved via the imaging studies was 2.5%.

A key study finding was that none of the 79 lung cancers that were diagnosed within 5 years following pneumonia occurred in patients younger than age 40 years at the time of their lung infection, and only five cases occurred in 40- to 49-year-olds. The investigators identified three independent risk factors associated with lung cancer within 5 years after an episode of pneumonia: age 50 years or more, with a relative risk of 19; male sex, with a 1.8-fold increased risk; and current smoking, with a relative risk of 1.7.

Dr. Keith predicted that most health care systems are going to endorse the lung cancer screening strategy that proved so successful in the landmark National Lung Screening Trial (N. Engl. J. Med. 2011;365:395-409). That study in more than 50,000 subjects showed that screening via low-dose helical chest CT reduced lung cancer mortality by 20%, compared with screening by chest x-ray in high-risk patients as defined mainly by their age and smoking history.

Based upon the results of this National Cancer Institute–sponsored study and other recent lung cancer screening studies, the National Comprehensive Cancer Network has recommended routine screening using low-dose helical CT for two high-risk groups: individuals aged 55-74 years with at least 30 pack-years of smoking who either are current smokers or who quit fewer than 15 years ago, and patients aged 50 or older with at least 20 pack-years of smoking and one additional risk factor. The additional risk factors are contact with radon, occupational exposure to asbestos or other carcinogens, a history of lung cancer in a first-degree relative, a personal history of any tobacco-related aerodigestive cancer, or chronic obstructive pulmonary disease.

Dr. Keith reported that he serves on the speakers bureaus for Boehringer Ingelheim and Pfizer.

COVINGTON, KY. – Racemic epinephrine may be more effective in premature than in full-term infants who are hospitalized for bronchiolitis, a chart review suggests.

The positive response rate to inhaled racemic epinephrine was significantly higher at 54.3% among premature infants, compared with 28% among full-term infants (P = .003).

In contrast, there was no significant difference in documented positive response rates to albuterol (Proventil, Ventolin, Volmax, Vospire) among premature and full-term infants (43.4% vs. 38%; P = .18), Dr. Russell J. McCulloh reported in a poster at the Pediatric Hospital Medicine 2012 meeting.

He said that few studies have examined the effectiveness of commonly used bronchiolitis therapies in children with a history of premature birth, even though these children are commonly affected by bronchiolitis and are at higher risk of severe outcomes and prolonged stay.

The chart review included 1,222 infants with and without a history of premature birth who were admitted for bronchiolitis to two academic medical centers. Of these, 229 (19%) were premature.

At baseline, preemies were significantly older than full-term infants (6.6 months vs. 5.4 months) and less likely to have day care exposure (15.3% vs. 24%), but more likely to have a history of wheeze (18% vs. 14%).

Premature patients had a significantly longer mean length of stay of 3.8 days compared with 2.5 days among full-term infants, although this did not differ significantly based on systemic steroid use (31% vs. 27.6%; P = .3), noted Dr. McCulloh of the pediatrics division at Rhode Island Hospital, Providence.

Premature infants were significantly more likely than full-term infants to require an ICU stay (23% vs. 11%), and they trended toward more pneumonia diagnosed (9.3% vs. 6%) and IV hydration (63% vs. 58.4%).

Full-term infants had more fever documented (45% vs. 36%) and urinary tract infections diagnosed (2.4% vs. 0%).

In logistic regression analyses, premature birth was independently associated with improved responsiveness to epinephrine (odds ratio, 1.89), Dr. McCulloh reported at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Dr. McCulloh reported having no conflicts of interest.

COVINGTON, KY. – Racemic epinephrine may be more effective in premature than in full-term infants who are hospitalized for bronchiolitis, a chart review suggests.

The positive response rate to inhaled racemic epinephrine was significantly higher at 54.3% among premature infants, compared with 28% among full-term infants (P = .003).

In contrast, there was no significant difference in documented positive response rates to albuterol (Proventil, Ventolin, Volmax, Vospire) among premature and full-term infants (43.4% vs. 38%; P = .18), Dr. Russell J. McCulloh reported in a poster at the Pediatric Hospital Medicine 2012 meeting.

He said that few studies have examined the effectiveness of commonly used bronchiolitis therapies in children with a history of premature birth, even though these children are commonly affected by bronchiolitis and are at higher risk of severe outcomes and prolonged stay.

The chart review included 1,222 infants with and without a history of premature birth who were admitted for bronchiolitis to two academic medical centers. Of these, 229 (19%) were premature.

At baseline, preemies were significantly older than full-term infants (6.6 months vs. 5.4 months) and less likely to have day care exposure (15.3% vs. 24%), but more likely to have a history of wheeze (18% vs. 14%).

Premature patients had a significantly longer mean length of stay of 3.8 days compared with 2.5 days among full-term infants, although this did not differ significantly based on systemic steroid use (31% vs. 27.6%; P = .3), noted Dr. McCulloh of the pediatrics division at Rhode Island Hospital, Providence.

Premature infants were significantly more likely than full-term infants to require an ICU stay (23% vs. 11%), and they trended toward more pneumonia diagnosed (9.3% vs. 6%) and IV hydration (63% vs. 58.4%).

Full-term infants had more fever documented (45% vs. 36%) and urinary tract infections diagnosed (2.4% vs. 0%).

In logistic regression analyses, premature birth was independently associated with improved responsiveness to epinephrine (odds ratio, 1.89), Dr. McCulloh reported at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Dr. McCulloh reported having no conflicts of interest.

COVINGTON, KY. – Racemic epinephrine may be more effective in premature than in full-term infants who are hospitalized for bronchiolitis, a chart review suggests.

The positive response rate to inhaled racemic epinephrine was significantly higher at 54.3% among premature infants, compared with 28% among full-term infants (P = .003).

In contrast, there was no significant difference in documented positive response rates to albuterol (Proventil, Ventolin, Volmax, Vospire) among premature and full-term infants (43.4% vs. 38%; P = .18), Dr. Russell J. McCulloh reported in a poster at the Pediatric Hospital Medicine 2012 meeting.

He said that few studies have examined the effectiveness of commonly used bronchiolitis therapies in children with a history of premature birth, even though these children are commonly affected by bronchiolitis and are at higher risk of severe outcomes and prolonged stay.

The chart review included 1,222 infants with and without a history of premature birth who were admitted for bronchiolitis to two academic medical centers. Of these, 229 (19%) were premature.

At baseline, preemies were significantly older than full-term infants (6.6 months vs. 5.4 months) and less likely to have day care exposure (15.3% vs. 24%), but more likely to have a history of wheeze (18% vs. 14%).

Premature patients had a significantly longer mean length of stay of 3.8 days compared with 2.5 days among full-term infants, although this did not differ significantly based on systemic steroid use (31% vs. 27.6%; P = .3), noted Dr. McCulloh of the pediatrics division at Rhode Island Hospital, Providence.

Premature infants were significantly more likely than full-term infants to require an ICU stay (23% vs. 11%), and they trended toward more pneumonia diagnosed (9.3% vs. 6%) and IV hydration (63% vs. 58.4%).

Full-term infants had more fever documented (45% vs. 36%) and urinary tract infections diagnosed (2.4% vs. 0%).

In logistic regression analyses, premature birth was independently associated with improved responsiveness to epinephrine (odds ratio, 1.89), Dr. McCulloh reported at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Dr. McCulloh reported having no conflicts of interest.

The ability to detect the recently circulating influenza variant H3N2v was low in some commercially available rapid detection tests, according to an analysis conducted by the Centers for Disease Control and Prevention.

"The ability to detect H3N2v virus varied substantially among the tests. This evaluation emphasizes the fact that a negative [rapid influenza detection test (RIDT)] result should not be considered as conclusive evidence of lack of infection with influenza A (H3N2)v ... Results from RIDTs, both positive and negative, always should be interpreted in the broader context of the circulating influenza strains present in the area, level of clinical suspicion, severity of illness, and risk for complications in a patient with suspected infection," the CDC said Aug. 10 in an early online release from Morbidity and Mortality Weekly Report (2012;61:1-3).

CDC/ Dr. Michael Shaw; Doug Jordan, M.A.

The H3N2v viruses can be definitively identified only at qualified U.S. public health laboratories using a polymerase chain reaction–based influenza diagnostic panel that is not available as a point-of-care test for clinicians. Specimens that test positive for influenza A, H3, and pandemic influenza A markers and negative for H1 and pandemic H1 markers are called "presumptive positive for influenza A(H3N2)v virus," until confirmed as influenza A(H3N2)v, the CDC said.

The CDC analyzed seven Food and Drug Administration–cleared rapid influenza detection tests (RIDTs) for their ability to detect H3N2v viruses, of which 153 infections were reported from four states between July 12 and Aug. 9, 2012. Each of the seven RIDTs – the BinaxNOW, Directigen, FluAlert, QuickVue, Sofia, Xpect, and Veritor – was tested with seven different H3N2 viruses, according to their respective package instructions. Positive and negative controls contained in each RIDT were run before testing the viruses in the study to verify performance of each assay lot, with the exception of FluAlert, which does not provide controls.

Only four of the seven RIDTs (Directigen, Sofia, Veritor, and Xpect) detected all influenza A(H3N2)v viruses. BinaxNOW detected five of seven, and QuickVue detected three of seven. FluAlert detected only one of seven, the CDC said.

More data are needed on the clinical performance of all RIDTs in detecting H3N2v virus in various respiratory specimens, the CDC said.

Clinicians should minimize the occurrence of false RIDT results by strictly following the manufacturer’s instructions, collecting specimens soon after the onset of influenza-like illness – ideally within the first 72 hours – and confirming RIDT results by sending the specimen to a public health laboratory. Additional CDC guidance on interpretation of RIDTs for testing of patients with suspected H3N2v infection is available here.

No disclosure statement was listed.

The ability to detect the recently circulating influenza variant H3N2v was low in some commercially available rapid detection tests, according to an analysis conducted by the Centers for Disease Control and Prevention.

"The ability to detect H3N2v virus varied substantially among the tests. This evaluation emphasizes the fact that a negative [rapid influenza detection test (RIDT)] result should not be considered as conclusive evidence of lack of infection with influenza A (H3N2)v ... Results from RIDTs, both positive and negative, always should be interpreted in the broader context of the circulating influenza strains present in the area, level of clinical suspicion, severity of illness, and risk for complications in a patient with suspected infection," the CDC said Aug. 10 in an early online release from Morbidity and Mortality Weekly Report (2012;61:1-3).

CDC/ Dr. Michael Shaw; Doug Jordan, M.A.

The H3N2v viruses can be definitively identified only at qualified U.S. public health laboratories using a polymerase chain reaction–based influenza diagnostic panel that is not available as a point-of-care test for clinicians. Specimens that test positive for influenza A, H3, and pandemic influenza A markers and negative for H1 and pandemic H1 markers are called "presumptive positive for influenza A(H3N2)v virus," until confirmed as influenza A(H3N2)v, the CDC said.

The CDC analyzed seven Food and Drug Administration–cleared rapid influenza detection tests (RIDTs) for their ability to detect H3N2v viruses, of which 153 infections were reported from four states between July 12 and Aug. 9, 2012. Each of the seven RIDTs – the BinaxNOW, Directigen, FluAlert, QuickVue, Sofia, Xpect, and Veritor – was tested with seven different H3N2 viruses, according to their respective package instructions. Positive and negative controls contained in each RIDT were run before testing the viruses in the study to verify performance of each assay lot, with the exception of FluAlert, which does not provide controls.

Only four of the seven RIDTs (Directigen, Sofia, Veritor, and Xpect) detected all influenza A(H3N2)v viruses. BinaxNOW detected five of seven, and QuickVue detected three of seven. FluAlert detected only one of seven, the CDC said.

More data are needed on the clinical performance of all RIDTs in detecting H3N2v virus in various respiratory specimens, the CDC said.

Clinicians should minimize the occurrence of false RIDT results by strictly following the manufacturer’s instructions, collecting specimens soon after the onset of influenza-like illness – ideally within the first 72 hours – and confirming RIDT results by sending the specimen to a public health laboratory. Additional CDC guidance on interpretation of RIDTs for testing of patients with suspected H3N2v infection is available here.

No disclosure statement was listed.

The ability to detect the recently circulating influenza variant H3N2v was low in some commercially available rapid detection tests, according to an analysis conducted by the Centers for Disease Control and Prevention.

"The ability to detect H3N2v virus varied substantially among the tests. This evaluation emphasizes the fact that a negative [rapid influenza detection test (RIDT)] result should not be considered as conclusive evidence of lack of infection with influenza A (H3N2)v ... Results from RIDTs, both positive and negative, always should be interpreted in the broader context of the circulating influenza strains present in the area, level of clinical suspicion, severity of illness, and risk for complications in a patient with suspected infection," the CDC said Aug. 10 in an early online release from Morbidity and Mortality Weekly Report (2012;61:1-3).

CDC/ Dr. Michael Shaw; Doug Jordan, M.A.

The H3N2v viruses can be definitively identified only at qualified U.S. public health laboratories using a polymerase chain reaction–based influenza diagnostic panel that is not available as a point-of-care test for clinicians. Specimens that test positive for influenza A, H3, and pandemic influenza A markers and negative for H1 and pandemic H1 markers are called "presumptive positive for influenza A(H3N2)v virus," until confirmed as influenza A(H3N2)v, the CDC said.

The CDC analyzed seven Food and Drug Administration–cleared rapid influenza detection tests (RIDTs) for their ability to detect H3N2v viruses, of which 153 infections were reported from four states between July 12 and Aug. 9, 2012. Each of the seven RIDTs – the BinaxNOW, Directigen, FluAlert, QuickVue, Sofia, Xpect, and Veritor – was tested with seven different H3N2 viruses, according to their respective package instructions. Positive and negative controls contained in each RIDT were run before testing the viruses in the study to verify performance of each assay lot, with the exception of FluAlert, which does not provide controls.

Only four of the seven RIDTs (Directigen, Sofia, Veritor, and Xpect) detected all influenza A(H3N2)v viruses. BinaxNOW detected five of seven, and QuickVue detected three of seven. FluAlert detected only one of seven, the CDC said.

More data are needed on the clinical performance of all RIDTs in detecting H3N2v virus in various respiratory specimens, the CDC said.

Clinicians should minimize the occurrence of false RIDT results by strictly following the manufacturer’s instructions, collecting specimens soon after the onset of influenza-like illness – ideally within the first 72 hours – and confirming RIDT results by sending the specimen to a public health laboratory. Additional CDC guidance on interpretation of RIDTs for testing of patients with suspected H3N2v infection is available here.

No disclosure statement was listed.

There has been a "significant increase" in the number of detected human infections involving the H3N2 variant virus, according to the Centers for Disease Control and Prevention. A total of 16 cases – out of 29 overall – have been reported in the last 3 weeks.

All 12 of the most recently reported cases occurred in people who had direct or indirect contact with swine prior to their illness, the CDC reported on Aug. 3. They occurred in Hawaii, Ohio, and Indiana.

CDC/ Dr. Michael Shaw; Doug Jordan, M.A.

All 29 cases identified since July 2011 are due to an H3N2 variant, or H3N2v, virus that contains the M gene from the human influenza A(H1N1)pdm09 (2009 H1N1) virus. "This M gene may confer increased transmissibility to and among humans compared with other variant influenza viruses," Dr. Joseph Bresse, a medical epidemiologist with the CDC’s influenza division, said during a telephone press conference sponsored by the CDC. Among this overall total, 1 was detected in Hawaii, 7 in Indiana, 3 in Iowa, 10 in Ohio, 2 in Maine, 3 in Pennsylvania, 1 in Utah and 2 in West Virginia.

Overall, 23 cases involved swine contact prior to illness onset and 19 cases were associated with state agricultural fairs, where swine were present.

Signs and symptoms of H3N2v virus infection are similar to those caused by other respiratory infections, including seasonal influenza virus infection. If H3N2v virus infection is suspected because of recent exposure to pigs, testing of respiratory specimens should be performed at a state health department; rapid influenza diagnostic tests may not detect H3N2v virus in human respiratory specimens, resulting in false negative results.

Two antivirals – oseltamivir (Tamiflu) and zanamivir (Relenza) – have been approved by the Food and Drug Administration for the treatment of illness associated with H3N2v virus infection. Antiviral treatment is most effective when started as soon as possible after illness onset, according to the CDC.

There has been no human-to-human transmission among the 12 recent cases, according to Dr. Bresse. However, three cases since July 2011 have been due to human-to-human transmission. Likewise, no deaths or hospitalizations have been associated with the most recent cases, though there have been three hospitalizations overall required for individuals with underlying diseases that put them at higher risk from the infection.

Thirteen of the infections occurred in children, which is consistent with research studies demonstrating that children may be more susceptible to the infection than adults.

Dr. Bresse noted that influenza viruses have not been shown to be transmissible to people through eating properly handled and prepared pork (pig meat) or other products derived from pigs.

The CDC has developed a variant vaccine candidate that will be undergoing clinical trials later this year.

For information on the prevention of infection with the H3N2v virus, see the CDC’s fact sheet. For information on the proper handling of livestock, see the Animal Contact Compendium published by the National Association of State Public Health Veterinarians.

There has been a "significant increase" in the number of detected human infections involving the H3N2 variant virus, according to the Centers for Disease Control and Prevention. A total of 16 cases – out of 29 overall – have been reported in the last 3 weeks.

All 12 of the most recently reported cases occurred in people who had direct or indirect contact with swine prior to their illness, the CDC reported on Aug. 3. They occurred in Hawaii, Ohio, and Indiana.

CDC/ Dr. Michael Shaw; Doug Jordan, M.A.

All 29 cases identified since July 2011 are due to an H3N2 variant, or H3N2v, virus that contains the M gene from the human influenza A(H1N1)pdm09 (2009 H1N1) virus. "This M gene may confer increased transmissibility to and among humans compared with other variant influenza viruses," Dr. Joseph Bresse, a medical epidemiologist with the CDC’s influenza division, said during a telephone press conference sponsored by the CDC. Among this overall total, 1 was detected in Hawaii, 7 in Indiana, 3 in Iowa, 10 in Ohio, 2 in Maine, 3 in Pennsylvania, 1 in Utah and 2 in West Virginia.

Overall, 23 cases involved swine contact prior to illness onset and 19 cases were associated with state agricultural fairs, where swine were present.

Signs and symptoms of H3N2v virus infection are similar to those caused by other respiratory infections, including seasonal influenza virus infection. If H3N2v virus infection is suspected because of recent exposure to pigs, testing of respiratory specimens should be performed at a state health department; rapid influenza diagnostic tests may not detect H3N2v virus in human respiratory specimens, resulting in false negative results.

Two antivirals – oseltamivir (Tamiflu) and zanamivir (Relenza) – have been approved by the Food and Drug Administration for the treatment of illness associated with H3N2v virus infection. Antiviral treatment is most effective when started as soon as possible after illness onset, according to the CDC.

There has been no human-to-human transmission among the 12 recent cases, according to Dr. Bresse. However, three cases since July 2011 have been due to human-to-human transmission. Likewise, no deaths or hospitalizations have been associated with the most recent cases, though there have been three hospitalizations overall required for individuals with underlying diseases that put them at higher risk from the infection.

Thirteen of the infections occurred in children, which is consistent with research studies demonstrating that children may be more susceptible to the infection than adults.

Dr. Bresse noted that influenza viruses have not been shown to be transmissible to people through eating properly handled and prepared pork (pig meat) or other products derived from pigs.

The CDC has developed a variant vaccine candidate that will be undergoing clinical trials later this year.

For information on the prevention of infection with the H3N2v virus, see the CDC’s fact sheet. For information on the proper handling of livestock, see the Animal Contact Compendium published by the National Association of State Public Health Veterinarians.

There has been a "significant increase" in the number of detected human infections involving the H3N2 variant virus, according to the Centers for Disease Control and Prevention. A total of 16 cases – out of 29 overall – have been reported in the last 3 weeks.

All 12 of the most recently reported cases occurred in people who had direct or indirect contact with swine prior to their illness, the CDC reported on Aug. 3. They occurred in Hawaii, Ohio, and Indiana.

CDC/ Dr. Michael Shaw; Doug Jordan, M.A.

All 29 cases identified since July 2011 are due to an H3N2 variant, or H3N2v, virus that contains the M gene from the human influenza A(H1N1)pdm09 (2009 H1N1) virus. "This M gene may confer increased transmissibility to and among humans compared with other variant influenza viruses," Dr. Joseph Bresse, a medical epidemiologist with the CDC’s influenza division, said during a telephone press conference sponsored by the CDC. Among this overall total, 1 was detected in Hawaii, 7 in Indiana, 3 in Iowa, 10 in Ohio, 2 in Maine, 3 in Pennsylvania, 1 in Utah and 2 in West Virginia.

Overall, 23 cases involved swine contact prior to illness onset and 19 cases were associated with state agricultural fairs, where swine were present.

Signs and symptoms of H3N2v virus infection are similar to those caused by other respiratory infections, including seasonal influenza virus infection. If H3N2v virus infection is suspected because of recent exposure to pigs, testing of respiratory specimens should be performed at a state health department; rapid influenza diagnostic tests may not detect H3N2v virus in human respiratory specimens, resulting in false negative results.

Two antivirals – oseltamivir (Tamiflu) and zanamivir (Relenza) – have been approved by the Food and Drug Administration for the treatment of illness associated with H3N2v virus infection. Antiviral treatment is most effective when started as soon as possible after illness onset, according to the CDC.

There has been no human-to-human transmission among the 12 recent cases, according to Dr. Bresse. However, three cases since July 2011 have been due to human-to-human transmission. Likewise, no deaths or hospitalizations have been associated with the most recent cases, though there have been three hospitalizations overall required for individuals with underlying diseases that put them at higher risk from the infection.

Thirteen of the infections occurred in children, which is consistent with research studies demonstrating that children may be more susceptible to the infection than adults.

Dr. Bresse noted that influenza viruses have not been shown to be transmissible to people through eating properly handled and prepared pork (pig meat) or other products derived from pigs.

The CDC has developed a variant vaccine candidate that will be undergoing clinical trials later this year.

For information on the prevention of infection with the H3N2v virus, see the CDC’s fact sheet. For information on the proper handling of livestock, see the Animal Contact Compendium published by the National Association of State Public Health Veterinarians.

The Food and Drug Administration has approved the first generic versions of the leukotriene receptor antagonist Singulair to control asthma and relieve allergies. Singulair (montelukast sodium) is designed to treat symptoms in both adults and children.

For more information, visit the FDA's website.

The Food and Drug Administration has approved the first generic versions of the leukotriene receptor antagonist Singulair to control asthma and relieve allergies. Singulair (montelukast sodium) is designed to treat symptoms in both adults and children.

For more information, visit the FDA's website.

The Food and Drug Administration has approved the first generic versions of the leukotriene receptor antagonist Singulair to control asthma and relieve allergies. Singulair (montelukast sodium) is designed to treat symptoms in both adults and children.

For more information, visit the FDA's website.

Aclidinium bromide, a long-acting anticholinergic bronchodilator, has been approved as a treatment for chronic obstructive pulmonary disease, for the long-term maintenance treatment of bronchospasm associated with COPD, including chronic bronchitis and emphysema, the Food and Drug Administration announced on July 23.

The product, a dry powder inhaler used twice a day, will be marketed as Tudorza Pressair by Forest Pharmaceuticals, a subsidiary of Forest Laboratories. A statement released by Forest Laboratories said that the product was expected to become available to wholesalers in the fourth quarter of 2012. The inhaler delivers 60 doses of aclidinium bromide powder for inhalation, the statement said.

Approval was based on three randomized, placebo-controlled, confirmatory clinical trials, which included 1,276 patients aged 40 years and older diagnosed with COPD. At a meeting in February 2012, the majority of the FDA’s Pulmonary-Allergy Drugs Advisory Committee agreed that the data in clinical trials provided evidence that this dose had a clinically meaningful benefit in patients, citing the significant increases in trough forced expiratory volume in 1 second (FEV₁) from baseline (the primary efficacy end point) among those treated with 400 mcg twice a day, compared with those on placebo after 12 weeks of treatment in clinical studies.

The most common side effects reported by patients treated with aclidinium bromide included headache, nasopharyngitis, and cough. Serious adverse effects associated with treatment include paradoxical bronchospasm, new or worsened acute narrow-angle glaucoma, or new or worsened urinary retention, according to the FDA statement.

Forest Laboratories licensed the U.S. rights for aclidinium from Almirall, a pharmaceutical company based in Spain. In May, the Committee for Medicinal Products for Human Use of the European Medicines Agency has issued a positive opinion for approval of aclidinium for treating COPD in the E.U., where it will be marketed as Eklira Genuair, according to Almirall.

Aclidinium bromide, a long-acting anticholinergic bronchodilator, has been approved as a treatment for chronic obstructive pulmonary disease, for the long-term maintenance treatment of bronchospasm associated with COPD, including chronic bronchitis and emphysema, the Food and Drug Administration announced on July 23.

The product, a dry powder inhaler used twice a day, will be marketed as Tudorza Pressair by Forest Pharmaceuticals, a subsidiary of Forest Laboratories. A statement released by Forest Laboratories said that the product was expected to become available to wholesalers in the fourth quarter of 2012. The inhaler delivers 60 doses of aclidinium bromide powder for inhalation, the statement said.

Approval was based on three randomized, placebo-controlled, confirmatory clinical trials, which included 1,276 patients aged 40 years and older diagnosed with COPD. At a meeting in February 2012, the majority of the FDA’s Pulmonary-Allergy Drugs Advisory Committee agreed that the data in clinical trials provided evidence that this dose had a clinically meaningful benefit in patients, citing the significant increases in trough forced expiratory volume in 1 second (FEV₁) from baseline (the primary efficacy end point) among those treated with 400 mcg twice a day, compared with those on placebo after 12 weeks of treatment in clinical studies.

The most common side effects reported by patients treated with aclidinium bromide included headache, nasopharyngitis, and cough. Serious adverse effects associated with treatment include paradoxical bronchospasm, new or worsened acute narrow-angle glaucoma, or new or worsened urinary retention, according to the FDA statement.

Forest Laboratories licensed the U.S. rights for aclidinium from Almirall, a pharmaceutical company based in Spain. In May, the Committee for Medicinal Products for Human Use of the European Medicines Agency has issued a positive opinion for approval of aclidinium for treating COPD in the E.U., where it will be marketed as Eklira Genuair, according to Almirall.

Aclidinium bromide, a long-acting anticholinergic bronchodilator, has been approved as a treatment for chronic obstructive pulmonary disease, for the long-term maintenance treatment of bronchospasm associated with COPD, including chronic bronchitis and emphysema, the Food and Drug Administration announced on July 23.

The product, a dry powder inhaler used twice a day, will be marketed as Tudorza Pressair by Forest Pharmaceuticals, a subsidiary of Forest Laboratories. A statement released by Forest Laboratories said that the product was expected to become available to wholesalers in the fourth quarter of 2012. The inhaler delivers 60 doses of aclidinium bromide powder for inhalation, the statement said.

Approval was based on three randomized, placebo-controlled, confirmatory clinical trials, which included 1,276 patients aged 40 years and older diagnosed with COPD. At a meeting in February 2012, the majority of the FDA’s Pulmonary-Allergy Drugs Advisory Committee agreed that the data in clinical trials provided evidence that this dose had a clinically meaningful benefit in patients, citing the significant increases in trough forced expiratory volume in 1 second (FEV₁) from baseline (the primary efficacy end point) among those treated with 400 mcg twice a day, compared with those on placebo after 12 weeks of treatment in clinical studies.

The most common side effects reported by patients treated with aclidinium bromide included headache, nasopharyngitis, and cough. Serious adverse effects associated with treatment include paradoxical bronchospasm, new or worsened acute narrow-angle glaucoma, or new or worsened urinary retention, according to the FDA statement.

Forest Laboratories licensed the U.S. rights for aclidinium from Almirall, a pharmaceutical company based in Spain. In May, the Committee for Medicinal Products for Human Use of the European Medicines Agency has issued a positive opinion for approval of aclidinium for treating COPD in the E.U., where it will be marketed as Eklira Genuair, according to Almirall.