Ann Allergy Asthma Immunol 113 (2014) 499e501

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Guest Editorials

Why we should improve attendance at the annual meeting poster and abstract sessions

Let me begin by saying that since starting our training program at Penn State University I have required my fellows to attend 3 meetings a year: the American Academy of Allergy, Asthma and Immunology (AAAI), the American College of Allergy, Asthma and Immunology (ACAAI), and the Pennsylvania Allergy and Asthma Association (PAAA) meetings. They were also required to submit abstracts to the AAAAI and ACAAI and now also to the PAAA since they started an abstract program a couple years ago. I have been very pleased by these requirements and believe it is a great educational benefit for fellows, residents, and students. It places them in a position to develop a respect and interest in our professional organizations and to feel part of them, which I hope will lead them to become active members in the future. Times are changing. Youth entering medical schools now learn by methods much different than past generations. Didactic sessions are no longer considered a strategic method for learning. Instead team learning and electronic learning are preferred, and medical schools across the country are altering curriculum to adjust to the shift in learning.1 At the same time, interest in professional associations is waning. Membership in the American Medical Association (AMA) has been decreasing for more than a decade.2 Granted, political issues may be a factor in membership in the AMA, but data suggest that youth are quickly losing interest in associations even without conflicts of political idealism.3 Does the annual ACAAI meeting provide an opportunity for group learning? I would argue that the answer is yes, and abstracts are one opportunity to achieve active and group learning. Are didactics the main means to disseminate knowledge at our meetings? Again I would argue that the answer is yes, and this is a point that should concern us. Meetings need to be more than they currently are if we are to continue to attract our youth. Does anyone need to attend meetings to learn cutting-edge information? Do you need to attend the ACAAI meeting to obtain continuing medical education (CME) credit? To these 2 questions, the answer is no. In fact, I can read an emanuscript before it is ever published, and there are numerous ways to receive CME credit online. Why are the questions and answers above a concern for the ACAAI? Our annual meeting is based on didactics. Why would newly trained allergists attend if they no longer believe that didactic learning is a robust way to acquire information? Is

Disclosures: Author has nothing to disclose.

attendance at our meeting decreasing for this reason? Are there reasons to attend a professional meeting other than to view and listen to didactics. Comradeship, fellowship, and being part of a community are all reasons to attend. Are there ways that we can help facilitate these alternate reasons for meeting attendance? During the last few years, I have found myself questioning my requirements of my fellows to attend and present at the ACAAI meeting. My fellows, residents, and students have had abstracts every year and recently have had few if any visits to their abstract sessions at the ACAAI. Although most of their work is not suitable for science, they still learn from the process, and I guarantee that you and I can learn from them as well. Because the abstract sessions are not attended by many, both the presenting fellows and the other attendees are missing an opportunity for group learning. In addition, fellows are missing a great opportunity to develop a social structure based on interaction with members who visit their posters. Instead of being excited to be part of a fellowship, fellows are returning from the meeting feeling neglected and unappreciated. Their hard work goes unrecognized and unnoted. The reason I am concerned should be obvious, but most important are my suggestions to improve this. We need to show interest in our youth. Attending their poster presentations, interacting with them, developing a social tie, and learning from them (while they, in turn, learn from us) will serve us all well in the future. Remember, often the first introduction to the ACAAI is to present posters. Items that can enhance visiting the poster sessions are many and include strategic location of the posters, not having conflicting sessions, and having food and coffee within the poster session, but all this still requires attendees to show an interest in the individuals presenting their hard work. We have been considering making the poster sessions juried. This process gives each presenter a few minutes to summarize the poster and a few minutes for discussion. A group of attendees and a moderator go from poster to poster and allow presenters to defend their work. This system works well at the European Academy of Allergy and Clinical Immunology meeting, but attendance at the ACAAI poster sessions needs to improve before this system can be instituted. My appeal, to help ensure future membership for the ACAAI and optimal attendance at the annual meeting, is to visit our youth at their poster presentations, welcome them to our fellowship, and discuss their work. If you are lucky, you may even find yourself a partner. At the same time, I am hoping the ACAAI Board of Directors

http://dx.doi.org/10.1016/j.anai.2014.09.001 1081-1206/Ó 2014 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

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Guest Editorials / Ann Allergy Asthma Immunol 113 (2014) 499e501

will make modifications to the meeting to make it easier for us to attend the poster sessions. Timothy Craig, DO Department of Medicine and Pediatrics Penn State University Hershey, Pennsylvania [email protected]

References [1] Catanese L. Developing a Medical School Curriculum for the 21st Century. UConn Today. http://today.uconn.edu/blog/2014/04/developing-a-medicalschool-curriculum-for-the-21st-century/. Accessed September 15, 2014. [2] Collier R. American Medical Association membership woes continue. CMAJ. 2011;183:E713eE714. [3] News Medical. Survey finds professional societies face declining membership and growing expectations. September 13, 2013. http://www.news-medical.net/news/ 20130913/Survey-finds-professional-societies-face-declining-membership-andgrowing-expectations.aspx. Accessed September 15, 2014.

Aspirin exacerbated respiratory disease: the search for a biomarker Aspirin exacerbated respiratory disease (AERD) is an acquired phenotype of asthma that affects up to 2 million adults with asthma in the United States (4%e11% of adults with asthma).1 Eosinophilic chronic rhinosinusitis (CRS) with recurrent nasal polyposis and stereotypic respiratory reactions after the ingestion of cyclooxygenase 1 (COX-1) inhibitors distinguishes AERD from all other forms of adult asthma. Although the underlying cause and exact pathophysiologic mechanisms remain unknown, AERD is recognized as a disease of dysregulated cysteinyl leukotriene (cysLT) overproduction and airway hyperresponsiveness2 at baseline with further increases in cysLT production after challenge with COX-1 inhibitors.3 Despite the well-defined clinical and physiologic characteristics of AERD, including airway eosinophilia, recurrent nasal polyposis, excessive cysLT generation, and COX-1einduced respiratory reactions, reliable diagnostic methods are difficult and the response to available therapeutics is variable. Therefore, there is an urgent need for the discovery of an appropriate biomarker that could assist in diagnosis and predict the severity of aspirin-induced reactions. In the absence of an available biomarker, aspirin challenge is the criterion standard and most reliable method to confirm the diagnosis of AERD. Diagnostic aspirin challenges should be performed by an allergist or pulmonologist trained in the treatment of hypersensitivity reactions and anaphylaxis and require at least 4 to 8 hours of patient and physician time to complete, although occasionally 2-day protocols are needed. Aspirin challenges are resource intense and carry the potential for serious respiratory compromise, especially when the baseline forced expiratory volume in 1 second (FEV1) is below 70% of predicted. Therefore, a diagnostic alternative to aspirin challenge is highly desired by the clinician and the patient alike. Potential diagnostic biomarker candidates, including urinary leukotriene E4 levels, platelet leukocyte aggregates,4 tissue eosinophilia, and fractional exhaled nitric oxide, are either available only in research settings and/or are not specific enough to AERD to provide predictive value. And so the search for superior diagnostic methods continues. Recently, periostin has caught the attention of asthma researchers. Periostin, an extracellular matrix protein, was originally recognized as having a role in allergic inflammation in the disease state of eosinophilic esophagitis, where it was found to act downstream of transforming growth factor b and interleukin 13.5 Identified as a marker of response in asthmatic patients to treatment with the monoclonal antibody against interleukin 13 lebrikizumab6 and as a systemic biomarker of airway eosinophilia in asthmatic patients,7 periostin is connected to the TH2 inflammation and eosinophilia associated with asthma. Given the abundance of airway eosinophilia that accompanies AERD, it is not terribly surprising that the study by Kim and colleagues8 in a recent issue of the Annals reports a correlation between serum periostin and blood and sputum Disclosure: The author has nothing to disclose.

eosinophilia. This positive correlation between periostin and sputum eosinophil suggests that periostin levels may predict the baseline level of respiratory tissue inflammation. However, a decrease in FEV1 after lysine-aspirin bronchoprovocation testing does not correlate with serum periostin levels. This lack of correlation may be because the severity of bronchoconstriction induced by aspirin challenge is the result of acute release of bronchoconstrictive eicosanoids from activated tissue mast cells and not specifically due to eosinophilia. Because the aspirininduced respiratory reactions are pathognomonic for AERD, the lack of correlation between periostin levels and severity of aspirin reactions reduce the value of periostin as a biomarker. In addition, serum periostin levels are higher in individuals with AERD with more severe CRS compared with less severe CRS, likely reflecting the abundance of eosinophils in the inflammatory tissue of AERDassociated severe CRS. Univariate and multivariate analyses identify that severe asthma and serum periostin levels are associated with AERD, but the lower limit confidence intervals for both closely approach 1. Serum periostin levels are not changed by lysine-aspirin challenge. Taken together, periostin serves as a fair predictor of the eosinophilic inflammation characteristic of AERD and many other disease states but does not reliably distinguish AERD from the other eosinophilic phenotypes of asthma. And so the search for a true biomarker continues. Aspirin challenge will remain the criterion standard for diagnosing AERD until another tool can reliably and predictably identify these patients. The new information describing a correlation between serum periostin and blood and sputum eosinophilia in patients with AERD is an important addition to the field, but the pursuit of a specific biomarker of AERD should continue. In an ideal world, this biomarker would correlate with the parameters (decrease in FEV1 and sinonasal symptom score) that confirm a positive aspirin challenge result and would both track with disease severity and reflect the response to high-dose aspirin therapy. In addition, continued research efforts should focus on understanding the underlying pathophysiologic and causative mechanisms of AERD. If we are unable to understand this distinct and well-characterized phenotype of asthma, there is little hope for us to understand the many other phenotypes of the disease. Katherine N. Cahill, MD Tanya M. Laidlaw, MD Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts [email protected]

References [1] Stevenson DD, Szczeklik A. Clinical and pathologic perspectives on aspirin sensitivity and asthma. J Allergy Clin Immunol. 2006;118:773e786.

Why we should improve attendance at the annual meeting poster and abstract sessions.

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