Comparative effectiveness of Anti-IL5 and Anti-IgE biologic classes in patients with severe asthma eligible for both

BACKGROUND

Patients with severe asthma may present with characteristics representing overlapping phenotypes, making them eligible for more than one class of biologic. Our aim was to describe the profile of adult patients with severe asthma eligible for both anti-IgE and anti-IL5/5R and to compare the effectiveness of both classes of treatment in real life.

METHODS

This was a prospective cohort study that included adult patients with severe asthma from 22 countries enrolled into the International Severe Asthma registry (ISAR) who were eligible for both anti-IgE and anti-IL5/5R. The effectiveness of anti-IgE and anti-IL5/5R was compared in a 1:1 matched cohort. Exacerbation rate was the primary effectiveness endpoint. Secondary endpoints included long-term-oral corticosteroid (LTOCS) use, asthma-related emergency room (ER) attendance and hospital admissions.

RESULTS

In the matched analysis (n=350/group), the mean annualized exacerbation rate decreased by 47.1% in the anti-IL5/5R group and 38.7% in the anti-IgE group. Patients treated with anti-IL5/5R were less likely to experience a future exacerbation (adjusted IRR 0.76; 95% CI 0.64, 0.89; p<0.001) and experienced a greater reduction in mean LTOCS dose than those treated with anti-IgE (37.44% vs 20.55% reduction; p=0.023).) There was some evidence to suggest that patients treated with anti-IL5/5R experienced fewer asthma-related hospitalizations (IRR 0.64; 95% CI 0.38, 1.08), but not ER visits (IRR 0.94, 95% CI 0.61, 1.43).

CONCLUSIONS

In real life, both anti-IgE and anti-IL5/5R improve asthma outcomes in patients eligible for both biologic classes, however anti-IL5/5R was superior in terms of reducing asthma exacerbations and LTOCS use.

Asthma

Asthma is one of the most common chronic non-communicable diseases worldwide and is characterised by variable airflow obstruction, causing dyspnoea and wheezing. Highly effective therapies are available; asthma morbidity and mortality have vastly improved in the past 15 years, and most patients can attain good asthma control. However, undertreatment is still common, and improving patient and health-care provider understanding of when and how to adjust treatment is crucial. Asthma management consists of a cycle of assessment of asthma control and risk factors and adjustment of medications accordingly. With the introduction of biological therapies, management of severe asthma has entered the precision medicine era-a shift that is driving clinical ambitions towards disease remission. Patients with severe asthma often have co-existing conditions contributing to their symptoms, mandating a multidimensional management approach. In this Seminar, we provide a clinically focused overview of asthma; epidemiology, pathophysiology, diagnosis, and management in children and adults.

Ultra-low-dose CBCT scan: rational map for ear surgery

PURPOSE

This study will evaluate the clinical quality and usability of peripheral image data from the temporal bone area obtained using a sinonasal ultra-low-dose (ULD) cone-beam computed tomography (CBCT) scan and compare them to those obtained using a high-resolution (HR) CBCT.

METHODS

The population consisted of 66 anatomical sites (ears of 33 subjects) imaged using two modalities: an HR CBCT (Scanora 3Dx scanner; Soredex, Tuusula, Finland) and a ULD CBCT (Promax 3D Mid scanner; Plandent, Helsinki, Finland). The image quality (IQ) for every anatomical site in each image was rated using a Likert scale from 0 to 5.

RESULTS

The quality of ULD CBCT scans was clinically sufficient in over 95% of the assessed images of the sigmoid sinus, jugular bulb, epitympanum and mastoid antrum as well as external acoustic meatus (all p > 0.05 compared to HR CBCT). The IQ was clinically sufficient in 75-94% of the assessed images of the scutum, mastoid segment of the facial nerve, cochlea and semicircular canals (all p < 0.05 compared to HR CBCT). The overall IQ of the HR CBCT scans was good or excellent.

CONCLUSION

CBCT imaging and the data at image margins are underutilized. CBCT can produce excellent structural resolution with conventional imaging parameters, even with off-focus images. Using ultra-low doses of radiation, the produced IQ is clinically sufficient. We encourage ear surgeons to check the patients' imaging history and to consider the use of imaging modalities that involve lower radiation doses especially when conducting repetitive investigations and with children.

Prevalence and management of severe asthma in the Nordic countries – findings from the NORDSTAR cohort

Background

Real-life evidence on prevalence and management of severe asthma is limited. Nationwide population registries across the Nordic countries provide unique opportunities to describe prevalence and management patterns of severe asthma at population level.

Aim

In nationwide register data from Sweden, Norway, and Finland, we examined the prevalence of severe asthma and the proportion of severe asthma patients being managed in specialist care.

Methods

This is a cross-sectional study based on the NORdic Dataset for aSThmA Research (NORDSTAR) research collaboration platform. We identified patients with severe asthma in adults (≥18 years) and in children (6–17 years) in 2018 according to the ERS/ATS definition. Patients managed in specialist care were those with an asthma-related specialist outpatient contact (only available in Sweden and Finland).

Results

Overall, we identified 598 242 patients with current asthma in Sweden, Norway, and Finland in 2018. Among those, the prevalence of severe asthma was 3.5%, 5.4% and 5.2% in adults and 0.4%, 1.0%, and 0.3% in children in Sweden, Norway, and Finland, respectively. In Sweden and Finland, 37% and 40% of adult patients with severe asthma and ≥2 exacerbations were managed in specialist care; in children the numbers were 56% and 41%, respectively.

Conclusion

In three Nordic countries, population-based nationwide data demonstrated similar prevalence of severe asthma. In children, severe asthma was a rare condition. Notably, a large proportion of patients with severe asthma was not managed by a respiratory specialist, suggesting the need for increased recognition of severe asthma in primary care.

Nonrespiratory Diseases in Adults Without and With Asthma by Age at Asthma Diagnosis

BACKGROUND

Chronic nonrespiratory diseases are seemingly more prevalent in subjects with than without asthma, and asthma seems to differentiate by age of onset. However, studies with comparison of nonrespiratory diseases in subjects with and without asthma, considering asthma age of onset, are scarce.

OBJECTIVE

To compare the quantity and type of chronic nonrespiratory diseases in adults with and without asthma considering age at asthma diagnosis.

METHODS

In 2016, a FinEsS questionnaire was sent to 16,000 20- to 69-year-old adults randomly selected in Helsinki and Western Finland populations. Physician-diagnosed asthma was categorized to early (0-11), intermediate (12-39), and late-diagnosed (40-69 years).

RESULTS

A total of 8199 (51.5%) responded, and 842 (10.3%) reported asthma and age at diagnosis. In age and sex-adjusted binary logistic regression model, the most represented nonrespiratory disease was treated gastroesophageal reflux disease in early-diagnosed (odds ratio, 1.93; 95% CI, 1.17-3.19; P = .011) and osteoporosis in both intermediate-diagnosed (odds ratio, 3.45; 95% CI, 2.01-5.91; P < .001) and late-diagnosed asthma (odds ratio, 2.91; 95% CI, 1.77-4.79; P < .001), compared with subjects without asthma. In addition, gastroesophageal reflux disease, depression, sleep apnea, painful condition, and obesity were significantly more common in intermediate- and late-diagnosed asthma compared with without asthma, and similarly anxiety or panic disorder in intermediate-diagnosed and hypertension, severe cardiovascular disease, arrhythmia, and diabetes in late-diagnosed asthma. In age-adjusted analyses, having 3 or more nonrespiratory diseases was more common in intermediate (12.1%) and late-diagnosed asthma (36.2%) versus without asthma (10.4%) (both P < .001).

CONCLUSIONS

Nonrespiratory diseases were more common in adults with asthma than in adults without asthma. The type of nonrespiratory diseases differed, and their frequency increased by increasing age at asthma diagnosis.

Specialist Palliative Care Consultation for Patients with Nonmalignant Pulmonary Diseases: A Retrospective Study

Background

Few patients with chronic nonmalignant pulmonary diseases receive specialist palliative care consultation, despite their high symptom burden in end of life.

Objectives

To study palliative care decision making, survival, and hospital resource usage in patients with nonmalignant pulmonary diseases with or without a specialist palliative care consultation.

Methods

A retrospective chart review of all patients with a chronic nonmalignant pulmonary disease and a palliative care decision (palliative goal of therapy), who were treated in Tampere University Hospital, Finland, between January 1, 2018 and December 31, 2020.

Results

A total of 107 patients were included in the study, 62 (58%) had chronic obstructive pulmonary disease (COPD), and 43 (40%) interstitial lung disease (ILD). Median survival after palliative care decision was shorter in patients with ILD than in patients with COPD (59 vs. 213 days, p = 0.004). Involvement of a palliative care specialist in the decision making was not associated with the survival. Patients with COPD who received palliative care consultation visited less often emergency room (73% vs. 100%, p = 0.019) and spent fewer days in the hospital (7 vs. 18 days, p = 0.007) during the last year of life. When a palliative care specialist attended the decision making, the presence and opinions of the patients were recorded more often, and the patients were more frequently referred to a palliative care pathway.

Conclusions

Specialist palliative care consultation seems to enable better end-of-life care and supports shared decision making for patients with nonmalignant pulmonary diseases. Therefore, palliative care consultations should be utilized in nonmalignant pulmonary diseases preferably before the last days of life.

Multidisciplinary approaches to identifying and managing global airways disease: Expert recommendations based on qualitative discussions

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) and asthma frequently co-exist and share pathologic features. Taking a "global" treatment approach benefits diagnosis and treatment of both, but care is often siloed by specialty: joined-up clinics are uncommon. Our objectives were to explore expert opinion to give practical suggestions to identify adults needing global airways care; enhance cross-specialty working; and widen knowledge to support diagnosis and management, integrate with existing care pathways, and supplement existing guidelines.

Methods

Sixteen practicing physicians from northern Europe were invited for their national and/or international standing in treating asthma and/or chronic rhinosinusitis. Appreciative Inquiry techniques were used to guide their discussions.

Results

Key themes arising were screening and referral, collaboration on management, awareness and education, and research. Provided are screening criteria and suggestions for specialist referrals, and pointers for physicians to optimize their knowledge of global airways disease. Collaborative working is underscored, and practical suggestions are given for multidisciplinary teamworking within global airways clinics. Research gaps are identified.

Conclusion

This initiative provides practical suggestions for optimizing the care of adults with CRSwNP and asthma. Discussion of the role of allergy and drug exacerbations on these conditions, and care for patients with other global airways diseases were beyond scope; however, we expect some principles of our discussion will likely benefit patients with related conditions. The suggestions bridge asthma and CRSwNP management guidelines, envisioning interdisciplinary, global airway clinics relevant to various clinical settings. They highlight the value of joint screening for early recognition and referral of patients.

Are peanut oral food challenges still useful? An evaluation of children with suspected peanut allergy, sensitization to Ara h 2 and controlled asthma

BACKGROUND

Sensitization to Ara h 2 has been proposed as a promising biological marker for the severity of peanut allergy and may reduce the need for oral food challenges. This study aimed to evaluate whether peanut oral food challenge is still a useful diagnostic tool for children with suspected peanut allergy and an elevated level of Ara h 2-specific IgE. Additionally, we assessed whether well-controlled asthma is an additional risk for severe reactions.

METHODS

A retrospective analysis of 107 children with sensitization to Ara h 2-specific IgE (> 0.35 kU/l) undergoing open peanut challenges during 2012-2018 in the Tampere University Hospital Allergy Centre, Finland.

RESULTS

Of the 107 challenges, 82 (77%) were positive. Serum levels of Ara h 2 -sIgE were higher in subjects with a positive challenge than in those who remained negative (median 32.9 (IQR 6.7-99.8) vs. 2.1 (IQR 1.0-4.9) kU/l), p < 0.001) but were not significantly different between subjects with and without anaphylaxis. No correlation was observed between the serum level of Ara h 2-sIgE and reaction severity grading. Well-controlled asthma did not affect the challenge outcome.

CONCLUSIONS

Elevated levels of Ara h 2-specific IgE are associated with a positive outcome in peanut challenges but not a reliable predictor of reaction severity. Additionally, well-controlled asthma is not a risk factor for severe reactions in peanut challenges in children with sensitization to Ara h 2.

The burden of chronic rhinosinusitis with nasal polyps and its relation to asthma in Finland

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) is commonly associated with asthma. Treatment of CRSwNP includes intranasal and systemic corticosteroids, with non‐responsive patients commonly considered for endoscopic sinus surgery (ESS). This nationwide register‐based study evaluated the incidence, prevalence, and treatment burden of CRSwNP in Finland, and their association with the presence and severity of comorbid asthma.

Methods

Electronic health records of patients diagnosed with CRSwNP between 1.1.2012 and 31.12.2018 in Finnish specialty and primary care were included in the study. The patients were divided into subgroups based on presence, severity, and control of asthma: no asthma, mild to moderate asthma, severe controlled asthma, and severe uncontrolled asthma. A mean cumulative count of ESS was calculated over time per subgroup.

Results

The prevalence of CRSwNP increased from 602.2 to 856.7 patients per 100,000 population between years 2012 and 2019 (p < 0.001). A total of 18,563 patients (59.9% male) had incident CRSwNP between 2012 and 2019, with 27% having asthma, 6% having severe asthma, and 1.5% having severe uncontrolled asthma. In the no asthma, severe controlled asthma, and severe uncontrolled asthma subgroups, systemic corticosteroids were used by 54.1%, 94.9% and 99.3% (p < 0.001), respectively, while the ESS count 3 years post diagnosis was 0.49, 0.68 and 0.80, respectively.

Conclusions

The prevalence of CRSwNP showed a significant increase in the recent decade in Finland. Comorbid asthma, and in particular severe asthma, increased the probability of receiving systemic corticosteroids and undergoing ESS. Thus, improved management of CRSwNP in patients with comorbid asthma is urgently needed.

Heterogeneity in the use of biologics for severe asthma in Europe: a SHARP ERS study

Introduction

Treatment with biologics for severe asthma is informed by international and national guidelines and defined by national regulating bodies, but how these drugs are used in real-life is unknown.

Materials and methods

The European Respiratory Society (ERS) SHARP Clinical Research Collaboration conducted a three-step survey collecting information on asthma biologics use in Europe. Five geographically distant countries defined the survey questions, focusing on seven end-points: biologics availability and financial issues, prescription and administration modalities, inclusion criteria, continuation criteria, switching biologics, combining biologics and evaluation of corticosteroid toxicity. The survey was then sent to SHARP National Leads of 28 European countries. Finally, selected questions were submitted to a broad group of 263 asthma experts identified by national societies.

Results

Availability of biologics varied between countries, with 17 out of 28 countries having all five existing biologics. Authorised prescribers (pulmonologists and other specialists) also differed. In-hospital administration was the preferred deliverance modality. While exacerbation rate was used as an inclusion criterion in all countries, forced expiratory volume in 1 s was used in 46%. Blood eosinophils were an inclusion criterion in all countries for interleukin-5 (IL-5)-targeted and IL-4/IL-13-targeted biologics, with varying thresholds. There were no formally established criteria for continuing biologics. Reduction in exacerbations represented the most important benchmark, followed by improvement in asthma control and quality of life. Only 73% (191 out of 263) of surveyed clinicians assessed their patients for corticosteroid-induced toxicity.

Conclusion

Our study reveals important heterogeneity in the use of asthma biologics across Europe. To what extent this impacts on clinical outcomes relevant to patients and healthcare services needs further investigation.

This study, based on a three-step survey among 28 European countries, has demonstrated some similarities but also great disparities in the availability and use of biologics for severe asthma in Europehttps://bit.ly/3pqwlC5

Age at asthma diagnosis is related to prevalence and characteristics of asthma symptoms

Background

Although asthma may begin at any age, knowledge about relationship between asthma age of onset and the prevalence and character of different symptoms is scarce.

Objectives

The aim of this study was to investigate if adult-diagnosed asthma is associated with more symptoms and different symptom profiles than child-diagnosed asthma.

Methods

A FinEsS postal survey was conducted in a random sample of 16 000 20-69-year-old Finnish adults in 2016. Those reporting physician-diagnosed asthma and age at asthma diagnosis were included. Age 18 years was chosen to delineate child- and adult-diagnosed asthma.

Results

Of responders (N = 8199, 51.5%), 842 (10.3%) reported asthma diagnosis. Adult-diagnosed asthma was reported by 499 (59.3%) and child-diagnosed by 343 (40.7%). Of responders with adult-diagnosed and child-diagnosed asthma, 81.8% versus 60.6% used asthma medication (p < 0.001), respectively. Current asthma was also more prevalent in adult-diagnosed asthma (89.2% versus 72.0%, p < 0.001). Risk factors of attacks of breathlessness during the last 12 months were adult-diagnosis (OR = 2.41, 95% CI 1.64–3.54, p < 0.001), female gender (OR = 1.49, 1.07–2.08, p = 0.018), family history of asthma (OR = 1.48, 1.07–2.04, p = 0.018) and allergic rhinitis (OR = 1.49, 1.07–2.09, p = 0.019). All the analysed asthma symptoms, except dyspnea in exercise, were more prevalent in adult-diagnosed asthma in age- and gender-adjusted analyses (p = 0.032-<0.001) which was also more often associated with 5 or more asthma symptoms (p < 0.001) and less often with non-symptomatic appearance (p < 0.001) than child-diagnosed asthma.

Conclusion

Responders with adult-diagnosed asthma had more often current asthma and a higher and multiform asthma symptom burden, although they used asthma medication more often compared to responders with child-diagnosed asthma.

Long-Term Use of Short-Acting β2-Agonists in Patients With Adult-Onset Asthma

BACKGROUND

Short-term studies have associated high use of short-acting β₂-agonists (SABA) with increased risk of exacerbations, emergency visits, and asthma-related costs. However, no studies exist on long-term SABA use, and previous studies on the topic have not included information about adherence to inhaled corticosteroids (ICS) nor disease control, both affecting the need of SABA.

OBJECTIVE

To evaluate the clinical characteristics of SABA and ICS usage in newly diagnosed adult-onset asthma patients during a 12-year follow-up period.

METHODS

In the Seinäjoki Adult Asthma Study, 203 patients with adult-onset asthma were followed for 12 years. Information on dispensed SABA and ICS during the follow-up was obtained from the Finnish Social Insurance Institution. High SABA use was defined as ≥36 canisters in 12 years, corresponding to an average of ≥3 dispensed canisters/y.

RESULTS

Patients were dispensed median 6 (interquartile range: 3-16) SABA canisters and 48 (18-67) ICS canisters over 12 years, corresponding to 2 (1-4) and 11 (5-16) puffs/week, respectively. Only 10% of the patients were classified as high SABA users during this period. Obesity (body mass index ≥30) and high Airways Questionnaire 20 symptom scores at baseline predicted high long-term SABA use (incidence rate ratio: 1.53 [1.01-2.30] and 1.04 [1.00-1.08], respectively). High SABA users had higher ICS adherence, higher blood neutrophil counts, more comorbidities, and used more oral corticosteroid and antibiotic courses versus low SABA users.

CONCLUSION

High SABA use was infrequent in patients with confirmed adult-onset asthma. However, as high SABA use is associated with more severe asthma, these patients should be recognized in clinical practice.

Nasal nitric oxide is decreased in acute mild COVID-19 and related to viral load

Gaseous nitric oxide levels from the lungs (FeNO) and from the nose (nNO) have been demonstrated to react to acute infection or influenza vaccination. There are no published data on nNO levels during acute COVID-19, but normal levels of FeNO have been reported in one study. Our aim was to assess if acute mild COVID-19 alters nasal or bronchial NO output at the time of acute infection and at a 2-month follow up, and if this is related to symptoms or viral load. This study included 82 subjects with mild acute airway infection who did not need hospitalisation: 43 cases (RT-PCR-positive for SARS-CoV-2 in routine testing from nasopharynx) and 39 age- (+/- 5 years) and gender-matched controls (RT-PCR-negative for SARS-CoV-2). During acute infection, the cases had lower nNO compared to controls (526 [345-688] vs. 773 [677-929] ppb; p<0.001), but after two months, there was no significant difference between the groups (766 [597-965] vs. 893 [739-1066] ppb; p=0.162). There was no difference in FeNO between the groups at either of the visits. Nasal NO correlated with the cycle threshold (Ct) value of the nasopharyngeal RT-PCR test for SARS-CoV-2 (Spearman's rs=0.550; p<0.001), that is, nNO was lower with a higher viral load. Nasal NO output was decreased in acute COVID-19 in relation to higher viral load, suggesting that the type and intensity of inflammatory response affects the release of NO from airway mucosa. In these subjects without significant lower airway involvement, there were no clinically relevant findings regarding FeNO.

High training volume is associated with increased prevalence of non-allergic asthma in competitive cross-country skiers

Background

Cross-country skiers have a high prevalence of asthma, but its phenotypes and association with success in competitions are not known.

Objective

To investigate, by means of a postal survey, the relative proportions of allergic and non-allergic asthma in competitive cross-country skiers compared with the general population, to study how performance level and training volume are related to asthma and its type and to assess the possible risk factors for allergic and non-allergic asthma in competitive skiers.

Methods

All Finnish cross-country skiers enrolled in the largest national competitions in winter 2019 (n=1282), and a random sample (n=1754) of the general population of the same age were sent a postal questionnaire. The response rate was 27.4% (n=351) for skiers and 19.5% (n=338) for the controls. International Ski Federation (FIS) ranking points measured the level of success in skiers. Asthma was defined as self-reported, physician-diagnosed asthma. Asthma was considered allergic if associated with doctor-diagnosed allergy, and exposure to allergens provoked asthma symptoms.

Results

The prevalence of asthma was higher in skiers than in the controls (25.9% vs 9.2%, p<0.001), and it was the highest (56.1%) in the most successful quartile of skiers. Asthma was more often non-allergic in skiers than in the controls (60.1% vs 38.7%, p=0.036). Being a skier came with a higher risk for non-allergic (OR 5.05, 95% CI 2.65 to 9.61) than allergic asthma (OR 1.92, 1.08–3.42). Using multivariable regression analysis, training volume was associated with non-allergic asthma, while age, family history of asthma and allergic rhinitis were associated with allergic asthma.

Conclusion

The prevalence of asthma is the highest in the most successful cross-country skiers. The asthma in skiers is mostly non-allergic compared with the general population of the same age. The most important risk factor for non-allergic asthma in skiers is high training volume.

Regional variation in intensity of inhaled asthma medication and oral corticosteroid use in Denmark, Finland, and Sweden

Oral corticosteroids (OCS) are often prescribed to patients with asthma that remains uncontrolled with maintenance therapy. We performed a real-world analysis to describe the geographic distributions of patients with asthma and OCS dispensed in Nordic countries. This observational, retrospective study examined patient-level data from nationally prescribed drug registries from January to December 2018 for individuals aged ≥12 years in Denmark, Finland, and Sweden. Using an algorithm based on asthma treatment combinations defined by the Global Initiative for Asthma (GINA), we identified patients with asthma, those on GINA Step 4–5 treatments, and those being dispensed ≥2 courses of OCS and determined volumes of OCS dispensed to these patients over the 1-year analysis period. Data were plotted geographically within each country using colour-coded heat maps. The overall asthma prevalence rates were 7.4% in Denmark, 11.6% in Finland, and 8.1% in Sweden. In Denmark, Finland, and Sweden, respectively, the frequencies of patients on GINA Step 4–5 treatments were 19%, 15%, and 16%; among whom 10%, 23%, and 5% received ≥2 courses of OCS. The rates of patients on GINA Step 4–5 treatments who were dispensed OCS in each country were 23%, 30%, and 46%, of which 22%, 17%, and 10% were dispensed doses averaging ≥5 mg/day over the year. Heat maps revealed considerable heterogeneity in geographic densities of patients with asthma and OCS claims within each country. Taken together, these results demonstrate regional variations in estimated asthma severity, control, and OCS dispensed within and between countries. Patterns of medication use suggest that a high proportion of patients in Denmark, Finland, and Sweden are on GINA Step 4–5 treatments, many of whom are dispensed OCS; this poses a considerable corticosteroid burden to these patients. Geographic differences in medication use within and between Nordic countries may reflect variations in population characteristics and/or treatment approaches.

Eosinophilic airway diseases: basic science, clinical manifestations and future challenges

Eosinophils have a broad range of functions, both homeostatic and pathological, mediated through an array of cell surface receptors and specific secretory granules that promote interactions with their microenvironment. Eosinophil development, differentiation, activation, survival and recruitment are closely regulated by a number of type 2 cytokines, including interleukin (IL)-5, the key driver of eosinophilopoiesis. Evidence shows that type 2 inflammation, driven mainly by interleukin (IL)-4, IL-5 and IL-13, plays an important role in the pathophysiology of eosinophilic airway diseases, including asthma, chronic rhinosinusitis with nasal polyps, eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndrome. Several biologic therapies have been developed to suppress type 2 inflammation, namely mepolizumab, reslizumab, benralizumab, dupilumab, omalizumab and tezepelumab. While these therapies have been associated with clinical benefits in a range of eosinophilic diseases, their development has highlighted several challenges and directions for future research. These include the need for further information on disease progression and identification of treatable traits, including clinical characteristics or biomarkers that will improve the prediction of treatment response. The Nordic countries have a long tradition of collaboration using patient registries and Nordic asthma registries provide unique opportunities to address these research questions. One example of such a registry is the NORdic Dataset for aSThmA Research (NORDSTAR), a longitudinal population-based dataset containing all 3.3 million individuals with asthma from four Nordic countries (Denmark, Finland, Norway and Sweden). Large-scale, real-world registry data such as those from Nordic countries may provide important information regarding the progression of eosinophilic asthma, in addition to clinical characteristics or biomarkers that could allow targeted treatment and ensure optimal patient outcomes.

Outdoor pollen concentration is not associated with exercise-induced bronchoconstriction in children

BACKGROUND

Free running exercise test outdoors is an important method to diagnose asthma in children. However, the extent of how much exposure to pollens of outdoor air affects the results of the test is not known.

METHODS

We analyzed all reliable exercise challenge tests with impulse oscillometry in children (n = 799) between January 2012 and December 2014 in Tampere University Hospital. Pollen concentrations at the time of the test were collected from the register of Biodiversity Unit of the University of Turku. We compared the frequency of exercise-induced bronchoconstriction and pollen concentrations.

RESULTS

The analyses were restricted to birch and alder pollen as high counts of grass and mugwort pollen were so infrequent. The relative change in resistance at 5 Hz after exercise or the frequency of exercise-induced bronchoconstriction were not related to alder or birch pollen concentrations over 10 grains/m³ (p = 0.125-0.398). In logistic regression analysis comparing the effects of alder or birch pollen concentrations, immunoglobulin E (IgE)-mediated alder or birch allergy and absolute humidity over 10 g/m³ only absolute humidity was independently associated with change in airway resistance (odds ratio [OR]: 0.32, confidence interval [CI]: 0.13-0.67, p: 0.006).

CONCLUSIONS

In our large clinical sample, outdoor air pollen concentration was not associated with the probability of exercise-induced bronchoconstriction in free running test in children while low absolute humidity was the best predictor of airway obstruction.

Lung function during and after acute respiratory infection in COVID-19 positive and negative outpatients

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been associated with prolonged post-acute symptoms in at least 10% of patients [1, 2]. The majority of published data evaluates hospitalised patients with severe SARS-CoV-2 disease (COVID-19) with symptoms and pulmonary function defects several months after discharge [1]. Most of the infected subjects develop mild symptoms and are treated as outpatients. Though they are also reported to suffer from prolonged symptoms, their lung function is studied far less. Furthermore, the prolonged symptoms and objectively measurable findings are usually not compared to a group suffering from airway infection caused by other pathogens [2]. As spirometry and other aerosol-producing procedures are minimised during the pandemic, there are no reports on lung function during acute COVID-19.

At acute phase, outpatients with mild COVID-19 had more symptoms, higher small airway resistance and poorer lung elasticity compared to outpatients with other respiratory infections, but there was no difference between the groups after 2 monthshttps://bit.ly/3nalPye

NSAID-exacerbated respiratory disease (N-ERD): a population study

Background

Nonsteroidal anti-inflammatory drugs (NSAIDs) may exacerbate respiratory symptoms. A recent European Academy of Allergy and Clinical Immunology position paper recommended the use of an acronym, N-ERD (NSAID-exacerbated respiratory disease), for this hypersensitivity associated with asthma or chronic rhinosinusitis with or without nasal polyposis. Our aim was to estimate the prevalence of N-ERD and identify factors associated with N-ERD.

Methods

In 2016, a cross-sectional questionnaire survey of a random adult population of 16 000 subjects aged 20–69 years was performed in Helsinki and Western Finland. The response rate was 51.5%.

Results

The prevalence was 1.4% for N-ERD, and 0.7% for aspirin-exacerbated respiratory disease (AERD). The prevalence of N-ERD was 6.9% among subjects with asthma and 2.7% among subjects with rhinitis. The risk factors for N-ERD were older age, family history of asthma or allergic rhinitis, long-term smoking and exposure to environmental pollutants. Asthmatic subjects with N-ERD had a higher risk of respiratory symptoms, severe hypersensitivity reactions and hospitalisations than asthmatic subjects without N-ERD. The subphenotype of N-ERD with asthma was most symptomatic. Subjects with rhinitis associated with N-ERD, which would not be included in AERD, had the fewest symptoms.

Conclusion

We conclude that the prevalence of N-ERD was 1.4% in a representative Finnish adult population sample. Older age, family history of asthma or allergic rhinitis, cumulative exposure to tobacco smoke, secondhand smoke, and occupational exposures increased odds of N-ERD. N-ERD was associated with significant morbidity.

Population-based prevalence of N-ERD is 1.4%. N-ERD is symptomatic, with a rhinitis subgroup. The risk factors for N-ERD are older age, family history of asthma or allergic rhinitis, long-term smoking and exposure to environmental pollutants.https://bit.ly/3HxGftP

Clinical value of bronchodilator response for diagnosing asthma in steroid-naïve adults

Spirometry and testing for bronchodilator response have been recommended to detect asthma, and a bronchodilator response (BDR) of ≥12% and ≥200 mL has been suggested to confirm asthma. However, the clinical value of bronchodilation tests in newly diagnosed steroid-naïve adult patients with asthma remains unknown. We evaluated the sensitivity of BDR in forced expiratory volume in 1 s (FEV₁) as a diagnostic test for asthma in a real-life cohort of participants in the Seinäjoki Adult Asthma Study. In the diagnostic phase, 369 spirometry tests with bronchodilation were performed for 219 steroid-naïve patients. The fulfilment of each test threshold was assessed. According to the algorithm of the National Institute for Health and Care Excellence, we divided the patients into obstructive (FEV₁/forced vital capacity (FVC) <0.70) and non-obstructive (FEV₁/FVC ≥0.70) groups. Of the overall cohort, 35.6% fulfilled ΔFEV₁ ≥12% and ≥200 mL for the initial FEV₁, 18.3% fulfilled ΔFEV₁ ≥15% and ≥400 mL for the initial FEV₁, and 36.1% fulfilled ΔFEV₁ ≥9% of predicted FEV₁ at least once. One-third (31%) of these steroid-naïve patients was obstructive (pre-bronchodilator FEV₁/FVC <0.7). Of the obstructive patients, 55.9%, 26.5% and 48.5%, respectively, met the same thresholds. In multivariate logistic regression analysis, different thresholds recognised different kinds of asthma patients. In steroid-naïve adult patients, the current BDR threshold (ΔFEV₁ ≥12% and ≥200 mL) has low diagnostic sensitivity (36%) for asthma. In obstructive patients, sensitivity is somewhat higher (56%) but far from optimal. If the first spirometry test with bronchodilation is not diagnostic but asthma is suspected, spirometry should be repeated, and other lung function tests should be used to confirm the diagnosis.

Assessing Symptom Burden and Depression in Subjects With Chronic Respiratory Insufficiency

Objectives: Patients with chronic respiratory insufficiency suffer from advanced disease, but their overall symptom burden is poorly described. We evaluated the symptoms and screening of depression in subjects with chronic respiratory insufficiency by using the Edmonton symptom assessment system (ESAS). Methods: In this retrospective study, 226 subjects with chronic respiratory insufficiency answered the ESAS questionnaire measuring symptoms on a scale from 0 (no symptoms) to 10 (worst possible symptom), and the depression scale (DEPS) questionnaire, in which the cut-off point for depressive symptoms is 9. Results: The most severe symptoms measured with ESAS (median [interquartile range]) were shortness of breath 4.0 (1.0-7.0), dry mouth 3.0 (1.0-7.0), tiredness 3.0 (1.0-6.0), and pain on movement 3.0 (0.0-6.0). Subjects with a chronic obstructive pulmonary disease as a cause for chronic respiratory insufficiency had significantly higher scores for shortness of breath, dry mouth, and loss of appetite compared to others. Subjects with DEPS ≥9 reported significantly higher symptom scores in all ESAS categories than subjects with DEPS <9. The area under the receiver operating characteristic curve for ESAS depression score predicting DEPS ≥9 was 0.840 (P < .001). If the ESAS depression score was 0, there was an 89% probability of the DEPS being <9, and if the ESAS depression score was ≥4, there was an 89% probability of the DEPS being ≥9. The relation between ESAS depression score and DEPS was independent of subjects’ characteristics and other ESAS items. Conclusions: Subjects with chronic respiratory insufficiency suffer from a high symptom burden due to their advanced disease. The severity of symptoms increases with depression and 4 or more points in the depression question of ESAS should lead to a closer diagnostic evaluation of depression. Symptom-centered palliative care including psychosocial aspects should be early integrated into the treatment of respiratory insufficiency.

Sampling site for SARS-CoV-2 RT-PCR-An intrapatient four-site comparison from Tampere, Finland

BACKGROUND

SARS-CoV-2 diagnosis relies on the performance of nasopharyngeal swabs. Alternative sample sites have been assessed but the heterogeneity of the studies have made comparing different sites difficult.

OBJECTIVES

Our aim was to compare the performance of four different sampling sites for SARS-CoV-2 samples with nasopharynx being the benchmark.

STUDY DESIGN

COVID-19 positive patients were recruited prospectively, and samples were collected and analysed for SARS-CoV-2 with RT-PCR from all four anatomical sites in 43 patients, who provided written informed consent.

RESULTS

All anterior nasal and saliva samples were positive, while two oropharyngeal samples were negative. There was no significant difference in the cycle threshold values of nasopharyngeal and anterior nasal samples while saliva and oropharynx had higher cycle threshold values.

CONCLUSIONS

Anterior nasal swab performs as good as nasopharynx swab with saliva also finding all the positives but with higher cycle threshold values. Thus, we can conclude that anterior nasal swabs can be used for SARS-CoV-2 detection instead of nasopharyngeal swabs if the situation would require so.

Influence of Childhood Exposure to a Farming Environment on Age at Asthma Diagnosis in a Population-Based Study

Purpose

Asthma is a heterogeneous disease, and factors associated with different asthma phenotypes are poorly understood. Given the higher prevalence of farming exposure and late diagnosis of asthma in more rural Western Finland as compared with the capital of Helsinki, we investigated the relationship between childhood farming environment and age at asthma diagnosis.

Methods

A cross-sectional population-based study was carried out with subjects aged 20–69 years in Western Finland. The response rate was 52.5%. We included 3864 participants, 416 of whom had physician-diagnosed asthma at a known age and with data on the childhood environment. The main finding was confirmed in a similar sample from Helsinki. Participants were classified as follows with respect to asthma diagnosis: early diagnosis (0–11 years), intermediate diagnosis (12–39 years), and late diagnosis (40–69 years).

Results

The prevalence of asthma was similar both without and with childhood exposure to a farming environment (11.7% vs 11.3%). Allergic rhinitis, family history of asthma, ex-smoker, occupational exposure, and BMI ≥ 30 kg/m² were associated with a higher likelihood of asthma. Childhood exposure to a farming environment did not increase the odds of having asthma (aOR, 1.10; 95% CI, 0.87–1.40). It did increase the odds of late diagnosis (aOR, 2.30; 95% CI, 1.12–4.69), but the odds were lower for early (aOR, 0.49; 95% CI, 0.30–0.80) and intermediate diagnosis of asthma (aOR, 0.75; 95% CI, 0.47–1.18).

Conclusion

Odds were lower for early diagnosis of asthma and higher for late diagnosis of asthma in a childhood farming environment. This suggests a new hypothesis concerning the etiology of asthma when it is diagnosed late.

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