Asthma exacerbation in children: a practical review

Linkage of serum ITIH4 with Th2 signature cytokine, inflammation, exacerbation risk and severity in childhood asthma

Aim: ITIH4 has anti-inflammatory properties toward eosinophilic/neutrophilic inflammation. This study aimed to explore clinical value of ITIH4 in childhood asthma. Materials & methods: Serum ITIH4 and inflammatory cytokines were determined in 120 childhood asthma patients by enzyme-linked immunosorbent assay. Results: In the entire and acute exacerbation patients, ITIH4 positively associated with IFN-γ, but negatively related to proinflammatory cytokines. ITIH4 was lowest in patients with acute exacerbation, followed by chronic persistent, and highest in clinical remission. By receiver-operating characteristic analysis, ITIH4 potentially estimated acute exacerbation asthma risk. Moreover, ITIH4 negatively related to exacerbation severity in acute exacerbation patients. Conclusion: Serum ITIH4 negatively links with Th2 cell signature cytokine, proinflammatory cytokines, exacerbation risk and severity in childhood asthma.

The association between PM2.5 concentration and the severity of acute asthmatic exacerbation in hospitalized children: A retrospective study in Chongqing, China

BACKGROUND

Ambient PM2.5 is associated with asthma exacerbation. The association between the concentration of PM2.5 and the severity of asthma exacerbation has yet to be thoroughly clarified. The study aims to explore the association between the piror 30 days average concentration of PM2.5 and the severity of acute asthma exacerbation in hospitalized children.

METHODS

A total of 269 children with acute exacerbation of asthma were enrolled and divided into three groups according to the PM2.5 exposure concentrations: group 1 (PM2.5: <37.5 μg/m3 ), group 2 (PM2.5: 37.5-75 μg/m3 ), group 3 (PM2.5: ≥75 μg/m3 ), respectively. The ordered logistic regression modeling was conducted to explore the influence of daily PM2.5 concentration on the clinical severity of children's asthma exacerbation. Multiple linear regression was conducted to explore the association between the concentration of PM2.5 and the length of stay in the hospital (LOS). We also conducted a receiver operating characteristic (ROC) curve analysis to explore the cutoff value of PM2.5 to predict the children's asthma exacerbation.

RESULTS

There was no statistical difference among the three groups of children in gender, age, body mass index, ethnicity, the first diagnosis of asthma, allergic history, passive smoke exposure, or family history of asthma. There was a statistically significant difference in many hospitalization characteristics (p < 0.05) among the three groups of children. Significant differences were found in terms of accessory muscles of respiration (p = 0.005), respiratory failure (p = 0.012), low respiratory tract infectious (p = 0.020), and the severity of asthma exacerbation (p < 0.001) among the three groups. PM2.5 concentration was primarily positively correlated to neutrophile inflammation. The ordered multivariate logistic regression model showed that higher PM2.5 concentrations were significantly associated with greater odds of more severe asthma exacerbation in one and two-pollutant models. The adjusted odds ratio of severe asthma exacerbation was 1.029 (1.009, 1.049) in the one-pollutant model. The most significant odds ratio of severe asthma exacerbation was 1.050 (1.027, 1.073) when controlling NO2 in the two-pollutant models. Multiple linear regression showed that PM2.5 concentration was significantly associated with longer LOS in both one-pollutant and two-pollutant models. By performing ROC analysis, the average daily concentration of 44.5 µg/m3 of PM2.5 (AUC = 0.622, p = 0.002) provided the best performance to predict severe asthma of children exacerbation with a sensitivity of 59.2% and a specificity of 63.8%.

CONCLUSION

The increased prior 30 days average concentration of PM2.5 was associated with greater asthma exacerbation severity and longer length of stay in the hospital of children with asthma exacerbation.

Serum CDC42 reflects the exacerbation risk and severity, Th1/2 cell imbalance and inflammation in asthmatic children

Aim: To explore the clinical implication of serum CDC42 in asthmatic children. Materials & methods: Serum CDC42 from 80 asthmatic children experiencing exacerbation, 80 asthmatic children in remission and 40 healthy controls was detected by ELISA. Results: CDC42 was highest in asthmatic children experiencing exacerbation followed by asthmatic children in remission and healthy controls (p < 0.001). Among asthmatic children experiencing exacerbation, CDC42 positively correlated with exacerbation severity (p = 0.011), Th2 (p = 0.017), TNF-α (p < 0.001), IL-6 (p = 0.009) and IL-8 (p = 0.008) and negatively correlated with Th1/Th2 ratio (p = 0.028). In asthmatic children in remission, CDC42 correlated with lower Th1/Th2 ratio (p = 0.028) and higher TNF-α (p = 0.026). In healthy controls, CDC42 showed no correlation with Th1/2 or inflammatory cytokines. Conclusion: Circulating CDC42 reflects exacerbation risk, Th1/2 imbalance and inflammation in asthmatic children.

Knowledge, Attitudes, and Practices of Influenza Vaccination among Parents of Children with Asthma: A Cross-Sectional Study

Asthma is the most common chronic disease in childhood. Exacerbation is a significant problem for asthmatic patients, and viral infections remain the most frequent triggers of asthma exacerbations. This study explored knowledge, attitudes, and practices (KAP) of parents of asthmatic children towards providing influenza vaccine to their children. This cross-sectional study enrolled parents of asthmatic children who visited the outpatient respiratory clinics of two Jordanian hospitals. The present study enrolled 667 parents of asthmatic children (62.8% female). The median age of the participants' children was 7 years. The results showed that 60.4% of the children with asthma never received a flu vaccine. Most of those who had received the flu vaccine reported that the side effects were mild (62.7%). Asthma duration was positively and significantly associated with increased vaccine hesitancy/rejection (OR = 1.093, 95% CI = (1.004-1.190), p = 0.04; and OR = 1.092, 95% CI = (1.002-1.189), p = 0.044, respectively). As the attitude towards flu vaccine score increases, odds of vaccination hesitancy/rejection decreased (OR = 0.735, 95% CI = (0.676-0.800), p < 0.001; and OR = 0.571, 95% CI = (0.514-0.634), p < 0.001, respectively). The main reasons for vaccination hesitancy/refusal included "I don't think my child needs it" (22.3%) followed by "I forget it" (19.5%). The rate of vaccination among children was low and emphasized the necessity of encouraging parents with asthmatic children to vaccinate their children by conducting health awareness campaigns and also emphasized the role of doctors and other healthcare professionals.

Elevated Neutrophil-to-Lymphocyte Ratio Is Associated with Severe Asthma Exacerbation in Children

Asthma is the most common chronic respiratory disease in children. The neutrophil-to-lymphocyte ratio (NLR) is a marker of a chronic inflammatory state; however, data on the association of NLR with acute asthma exacerbations in children is lacking. In this cross-sectional study, between 2016 and 2021, children aged 2-18 years who were referred to the emergency department (ED) due to asthma exacerbation, were included. NLR, calculated from complete blood count upon arrival, was assessed as a continuous variable and was classified into four groups according to quartiles. The association between severity parameters and NLR quartiles was examined. A total of 831 ED visits for asthma exacerbation were included in the study. The median NLR was 1.6, 3.8, 6.7, and 12.9 in quartiles 1-4, respectively (p < 0.001). Demographic parameters, background diseases, and chronic medications were similar between the quartiles. Higher heart rate, body temperature, systolic blood pressure, and respiratory rate were observed in the higher NLR quartiles, as well as lower oxygen saturation. Higher urgency scale and higher rates of intravenous magnesium sulfate were observed in the higher NLR quartiles, with higher admission rates and prolonged hospitalizations. In summary, NLR upon admission is associated with the severity of asthma exacerbation and higher chances of hospitalization among children in the ED.

Indoor Aeroallergen Sensitization and Associated Factors in Hospitalized Children with Asthma Exacerbations

Background

Allergic asthma represents the most popular phenotype of childhood asthma and is characterized by eosinophilic airway inflammation associated with specific immunoglobulin E (IgE) antibodies sensitization to various allergens, as evidenced by serology or skin prick test.2 Sensitization to indoor aeroallergens is associated with severe asthma and severe asthma exacerbations.

Objective

This study aimed to identify the prevalence of aeroallergen sensitization and its associated factors in children with an asthma exacerbation in Vietnam.

Methods

A cross-sectional study was conducted at Children's Hospital 1, Ho Chi Minh City (HCMC). Children who were aged 3 to 15 and admitted to the hospital with moderate or severe asthma exacerbation were recruited to the study. Data was collected from interviews and medical records. SPT was used to identify aeroallergen sensitization. The association between school-age, living area, and passive smoking with the odds of aeroallergen sensitization was assessed using a multivariable logistic regression.

Results

The prevalence of aeroallergen sensitization was 82.6% and this figure in school-age children was higher than that in preschool-age ones (93.8% vs 72.1%, p=0.001). School-age, living in HCMC, and passive smoking significantly increased the odds of aeroallergen sensitization in asthmatic children with adjusted OR [95%CI] as 6.9 [2.1-23.3], 4.1 [1.5-11.5], and 2.9 [1.0-8.4], respectively. Asthmatic children with aeroallergen sensitization required more hours to resolve an asthma exacerbation than those without (22.4 vs 15.2, p=0.006).

Conclusion

Aeroallergen sensitization was common in hospitalized children with moderate or severe asthma exacerbation. It is necessary to establish environmental policy and screening practices of aeroallergen sensitization to improve the quality of asthma management for Vietnamese children.

Association of individual green space exposure with the incidence of asthma and allergic rhinitis: a systematic review and meta-analysis

The association between allergic respiratory diseases, such as asthma and allergic rhinitis (AR), and green space (GS) remains controversial. Our study aimed to summarize and synthesize the association between individual GS exposure and the incidence of asthma/AR. We systematically summarized the qualitative relationship between GS exposure and asthma and AR. The pooled odds ratio (OR) with 95% confidence intervals (CIs) was used to estimate the effect of the Normalized Difference Vegetation Index (NDVI) on asthma and AR. A total of 21 studies were included for systematic review, and 8 of them underwent meta-analysis. In the meta-analysis of current asthma, the 0 < radius ≤ 100 m group, 100 < radius ≤ 300 m group, and 500 < radius ≤ 1000 m group presented weak negative associations between the NDVI and current asthma. For ever asthma, slight positive associations existed in the 0 < radius ≤ 100 m group and 300 < radius ≤ 500 m group. In addition, the NDVI might slightly reduce the risk of AR in radius of 100 m and 500 m. Our findings suggest that the effects of GS exposure on asthma and AR were not significant. Differences in GS measurements, disease diagnoses and adjusted confounders across studies may have an impact on the results. Subsequent studies should consider potential confounding factors and use more accurate GS exposure measurements to better understand the impact of GS exposure on respiratory disease in the population.

Memory-like innate lymphoid cells in the pathogenesis of asthma

Innate lymphoid cells (ILCs) are recently discovered innate immune cells that reside and self-renew in mucosal tissues and serve as the first line of defense against various external insults. They include natural killer (NK) cells, ILC1s, ILC2s, ILC3s, and lymphoid tissue inducer cells. The development and functions of ILC1-3 reflect those of their adaptive immunity TH1, TH2, and TH17 T-cell counterparts. Asthma is a heterogeneous disease caused by repeated exposure to specific allergens or host/environmental factors (e.g., obesity) that stimulate pathogenic pulmonary immune cells, including ILCs. Memory used to be a hallmark of adaptive immune cells until recent studies of monocytes, macrophages, and NK cells showed that innate immune cells can also exhibit greater responses to re-stimulation and that these more responsive cells can be long-lived. Besides, a series of studies suggest that the tissue-resident innate lymphoid cells have memory-like phenotypes, such as increased cytokine productions or epigenetic modifications following repetitive exposure to allergens. Notably, both clinical and mouse studies of asthma show that various allergens can generate memory-like features in ILC2s. Here, we discuss the biology of ILCs, their roles in asthma pathogenesis, and the evidence supporting ILC memory. We also show evidence suggesting memory ILCs could help drive the phenotypic heterogeneity in asthma. Thus, further research on memory ILCs may be fruitful in terms of developing new therapies for asthma.

Probiotics in Children with Asthma

A type-2 immune response usually sustains wheezing and asthma in children. In addition, dysbiosis of digestive and respiratory tracts is detectable in patients with wheezing and asthma. Probiotics may rebalance immune response, repair dysbiosis, and mitigate airway inflammation. As a result, probiotics may prevent asthma and wheezing relapse. There is evidence that some probiotic strains may improve asthma outcomes in children. In this context, the PROPAM study provided evidence that two specific strains significantly prevented asthma exacerbations and wheezing episodes. Therefore, oral probiotics could be used as add-on asthma therapy in managing children with asthma, but the choice should be based on documented evidence.

MALT1 in asthma children: A potential biomarker for monitoring exacerbation risk and Th1/Th2 imbalance-mediated inflammation

BACKGROUND

Mucosa-associated lymphoid tissue lymphoma translocation protein 1 (MALT1) participates in the immune-related allergic response and inflammation flare, while its clinical role in asthma children is still unknown. Herein, this study aimed to investigate MALT1 expression, and its correlation with exacerbation risk, T helper (Th)1, Th2 cells (and their secreted cytokines), as well as inflammatory cytokines in asthma children.

METHODS

Sixty children with asthma exacerbation and 60 children with remission asthma were enrolled in this study; then their blood MALT1, Th1, Th2 cells, tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interferon-gamma (IFN-γ), and interleukin-4 (IL-4) were detected. Besides, blood MALT1 in another 20 health controls was also determined.

RESULTS

Mucosa-associated lymphoid tissue lymphoma translocation protein 1 was highest in children with asthma exacerbation, followed by children with remission asthma, and lowest in health controls (p < 0.001). MALT1 could distinguish children with asthma exacerbation from children with remission asthma (area under the curve (AUC): 0.757, 95% CI: 0.670-0.843). In children with asthma exacerbation, MALT1 was negatively linked with IFN-γ (p = 0.002) and Th1 cells (p = 0.050), but positively related to Th2 cells (p = 0.027) and exhibited a positive correlation trend (without statistical significance) with IL-4 (p = 0.066); meanwhile, MALT1 was positively correlated with exacerbation severity (p = 0.010) and TNF-α (p = 0.003), but not linked with IL-6 (p = 0.096). In children with remission asthma, MALT1 only was negatively associated with Th1 cells (p = 0.023), but positively linked with TNF-α (p = 0.023).

CONCLUSION

Mucosa-associated lymphoid tissue lymphoma translocation protein 1 serves as a potential biomarker for monitoring exacerbation risk and Th1/Th2 imbalance-mediated inflammation of asthma children.

Racial and Ethnic Disparities in Acute Care Use for Pediatric Asthma

PURPOSE

Previous work has shown that asthma-related emergency department (ED) use is greatest among Black and Latine populations, but it is unknown whether health care use for exacerbations differs across settings (outpatient, ED, inpatient) and correlates with use of routine outpatient services. We aimed to measure disparities by race, ethnicity, and language in pediatric acute asthma care using data from US primary care community health centers.

METHODS

In an observational study using electronic health records from community health centers in 18 states, we compared non-Hispanic Black, English-preferring Latine, Spanish-preferring Latine, and non-Hispanic White children aged 3 to 17 years on visits for clinic-coded asthma exacerbations (2012-2018). We further evaluated asthma-related ED use and inpatient admissions in a subsample of Oregon-Medicaid recipients. Covariate-adjusted odds ratios (ORs) and rate ratios (RRs) were derived using logistic or negative binomial regression analysis with generalized estimating equations.

RESULTS

Among 41,276 children with asthma, Spanish-preferring Latine children had higher odds of clinic visits for asthma exacerbation than non-Hispanic White peers (OR = 1.10; 95% CI, 1.02-1.18). Among the subsample of 6,555 children insured under Oregon-Medicaid, non-Hispanic Black children had higher odds and rates of asthma-related ED use than non-Hispanic White peers (OR = 1.40; 95% CI, 1.04-1.89 and RR = 1.49; 95% CI, 1.09-2.04, respectively). We observed no differences between groups in asthma-related inpatient admissions.

CONCLUSIONS

This study is the first to show that patterns of clinic and ED acute-care use differ for non-Hispanic Black and Spanish-preferring Latine children when compared with non-Hispanic White peers. Non-Hispanic Black children had lower use of clinics, whereas Spanish-preferring Latine children had higher use, including for acute exacerbations. These patterns of clinic use were accompanied by higher ED use among Black children. Ensuring adequate care in clinics may be important in mitigating disparities in asthma outcomes.VISUAL ABSTRACT.

The effect of the COVID-19 pandemic on non-COVID respiratory ED visits in Israel

Background

The COVID 19 pandemic has had a crucial effect on the patterns of disease and treatment in the healthcare system. This study examines the effect of the COVID-19 pandemic on respiratory ED visits and admissions broken down by age group and respiratory diagnostic category.

Methods

Data on non-COVID related ED visits and hospitalizations from the ED were obtained in a retrospective analysis for 29 acute care hospitals, covering 98% of ED beds in Israel, and analyzed by 5 age groups: under one-year-old, 1–17, 18–44, 45–74 and 75 and over. Diagnoses were classified into three categories: Upper respiratory tract infections (URTI), pneumonia, and COPD or asthma. Data were collected for the whole of 2020, and compared for each month to the average number of cases in the three pre-COVID years (2017–2019).

Results

In 2020 compared to 2017–2019, there was a decrease of 34% in non-COVID ED visits due to URTI, 40% for pneumonia and a 35% decrease for COPD and asthma. Reductions occurred in most age groups, but were most marked among infants under a year, during and following lockdowns, with an 80% reduction. Patients over 75 years old displayed a marked drop in URTI visits. Pediatric asthma visits fell during lockdowns, but spiked when restrictions were lifted, accompanied by a higher proportion admitted. The percent of admissions from the ED visits remained mostly stable for pneumonia; the percent of young adults admitted with URTI decreased significantly from March to October.

Conclusions

Changing patterns of ED use were probably due to a combination of a reduced rate of viral diseases, availability of additional virtual services, and avoidance of exposure to the ED environment. Improved hygiene measures during peaks of respiratory infections could be implemented in future to reduce respiratory morbidity; and continued provision of remote health services may reduce overuse of ED services for mild cases.

Vitamin D supplementation in childhood asthma: a systematic review and meta-analysis of randomised controlled trials

Background

There is conflicting evidence for vitamin D supplementation in childhood asthma. We aimed to systematically synthesise the evidence on the efficacy and safety of vitamin D supplementation in childhood asthma.

Methods

We searched electronic databases (Medline, Embase and Web of Science) and a register (CENTRAL) for randomised controlled trials (RCTs) published until 30 September 2021. RCTs enrolling asthmatic children (1–18 years old) and comparing vitamin D against placebo/routine care were included if they met at least one of the endpoints of interest (asthma attacks, emergency visits or hospitalisation). We used the Risk of Bias 2 tool for risk of bias assessment. Random-effects meta-analysis with RevMan 5.3 software was performed. The Grading of Recommendations Assessment, Development and Evaluation approach was used to assess the level of certainty of the evidence.

Results

18 RCTs (1579 participants) were included. The pooled meta-analysis did not find a significant effect of vitamin D supplementation on asthma attacks requiring rescue systemic corticosteroids (six studies with 445 participants; risk ratio (RR) 1.13, 95% CI 0.86–1.48; I²=0%) (moderate-certainty evidence). In addition, there was no significant difference in the proportion of children with asthma attacks of any severity (11 trials with 1132 participants; RR 0.84, 95% CI 0.65–1.09; I²=58%) (very low-certainty evidence). Vitamin D does not reduce the need for emergency visits (three studies with 361 participants; RR 0.97, 95% CI 0.89–1.07; I²=0%) and hospitalisation (RR: 1.38, 95% CI 0.52–3.66; I²=0%) (low-certainty evidence).

Conclusion

Very low- to moderate-certainty evidence suggests that vitamin D supplementation might not have any protective effect in childhood asthma.

Very low to moderate certainty evidence suggests that adjuvant vitamin D supplementation might not have any protective effect in childhood asthma. Therefore, routine vitamin D supplementation in asthmatic children should be avoided.https://bit.ly/3xQVitV

Could Interleukin-33 (IL-33) Govern the Outcome of an Equine Influenza Virus Infection? Learning from Other Species

Influenza A viruses (IAVs) are important respiratory pathogens of horses and humans. Infected individuals develop typical respiratory disorders associated with the death of airway epithelial cells (AECs) in infected areas. Virulence and risk of secondary bacterial infections vary among IAV strains. The IAV non-structural proteins, NS1, PB1-F2, and PA-X are important virulence factors controlling AEC death and host immune responses to viral and bacterial infection. Polymorphism in these proteins impacts their function. Evidence from human and mouse studies indicates that upon IAV infection, the manner of AEC death impacts disease severity. Indeed, while apoptosis is considered anti-inflammatory, necrosis is thought to cause pulmonary damage with the release of damage-associated molecular patterns (DAMPs), such as interleukin-33 (IL-33). IL-33 is a potent inflammatory mediator released by necrotic cells, playing a crucial role in anti-viral and anti-bacterial immunity. Here, we discuss studies in human and murine models which investigate how viral determinants and host immune responses control AEC death and subsequent lung IL-33 release, impacting IAV disease severity. Confirming such data in horses and improving our understanding of early immunologic responses initiated by AEC death during IAV infection will better inform the development of novel therapeutic or vaccine strategies designed to protect life-long lung health in horses and humans, following a One Health approach.

Evaluation of Risk Scores to Predict Pediatric Severe Asthma Exacerbations

BACKGROUND

Asthma exacerbations commonly lead to unplanned health care utilization and are costly. Early identification of children at increased risk of asthma exacerbations would allow a proactive management approach.

OBJECTIVE

We evaluated common asthma risk factors to predict the probability of exacerbation for individual children aged 0-21 years using data from the electronic medical record (EMR).

METHODS

We analyzed longitudinal EMR data for over 3000 participants with asthma seen at Cincinnati Children's Hospital Medical Center over a 7-year period. The study population was divided into 3 age groups: 0-4, 5-11, and 12-21 years. Each age group was divided into a derivation cohort and a validation cohort, which were used to build a risk score model. We predicted risk of exacerbation in the next 12 months, validated the scores by risk stratum, and developed a clinical tool to determine the risk level based on this model.

RESULTS

Risk model results were confirmed with validation cohorts by calendar year and age groups. Race, allergic sensitization, and smoke exposure were each important risk factors in the 0-4 age group. Abnormal spirometry and obesity were more sensitive predictors of exacerbation in children >12 years. For each age group, a higher expanded score was associated with a higher predicted probability of an asthma exacerbation in the subsequent year.

CONCLUSION

This asthma exacerbation prediction model, and the associated clinical tool, may assist clinicians in identifying children at high risk for exacerbation that may benefit from more aggressive management and targeted risk mitigation.

The effect of the COVID-19 lockdown on children with asthma-related symptoms: A tertiary care center experience

BACKGROUND

Acute asthma exacerbations are a common cause for emergency department (ED) visits and hospitalizations in children. Since the outbreak of coronavirus disease 2019 (COVID-19) and the education system closure/total lockdown in Israel on March 2020, we have noticed a decrease in pediatric ED visits and an increase in hospitalizations of asthma exacerbations.

OBJECTIVE

to examine the patterns of ED visits for asthma exacerbations during COVID-19 outbreak, in comparison to the previous year.

METHODS

A retrospective study comparing asthma related ED visits and hospitalizations among children aged 2-18 years at a tertiary center in southern Israel. Three time periods were selected: 2020 A (prelockdown, 2/1/20 to 3/14/20), 2020 B (lockdown, 3/15/20 to 5/15/20) and 2020 C (postlockdown, 5/16/20 to 6/30/20) and compared to the three parallel time periods in 2019. Data regarding demographics, number of ED visits and clinical severity parameters were collected and analyzed.

RESULTS

Five hundred and twelve children visited the ED for asthma exacerbation: 273 children during 2019 and 239 children during 2020. Lockdown period in 2020 revealed significantly fewer ED visits per day compared to the parallel calendar period in 2019 (1.8 vs. 1.43, p < .001). Significantly higher hospitalization rate (47.1% vs. 33.7%, p = .05) and longer length of stay (3.15 vs. 1.9 days, p = .03) were observed during the lockdown.

CONCLUSION

Lockdown is associated with fewer ED visits for asthma exacerbation, probably due to; reduced exposure to viral infections and environmental allergens, decreased availability of primary physicians and families' reluctance to arrive to the ED. ED visits during lockdown were characterized by higher hospitalization rate and longer LOS.

Reduced JKAP correlates with advanced disease features, inflammation, as well as increased exacerbation risk and severity in asthmatic children

BACKGROUND

This study aimed to investigate the correlation of JNK pathway-associated phosphatase (JKAP) with clinical features, inflammation, exacerbation risk, and severity in asthmatic children.

METHODS

Asthmatic exacerbation children (N = 90), asthmatic remission children (N = 90), and healthy controls (N = 90) were enrolled in this case-control study, whose venous blood samples were collected after enrollment for routine blood test, JKAP, and inflammatory cytokines detection by enzyme-linked immune sorbent assay. The clinical features included demographic data, family history of asthma, and pulmonary ventilation function.

RESULTS

JKAP level was the lowest in asthmatic exacerbation children, followed by asthmatic remission children and healthy controls. ROC curve revealed good ability of JKAP in distinguishing three groups from each other, especially in telling asthmatic exacerbation children from healthy controls (AUC: 0.926; 95%CI: 0.887-0.965). In addition, JKAP was negatively correlated with eosinophil count, immunoglobulin E (IgE), tumor necrosis factor alpha (TNF-α), interleukin-1 beta (IL-1β), interleukin-6 (IL-6), and interleukin-17 (IL-17), positively correlated with forced expiratory volume in 1 sec/forced vital capacity (FEV₁/FVC) and FEV₁ (%predicted) in asthmatic exacerbation children. Whereas in asthmatic remission children, JKAP was negatively correlated with eosinophil count, TNF-α, IL-1β, IL-6, and IL-17 and positively correlated with FEV₁ (%predicted), but not with IgE or FEV₁/FVC. In healthy controls, the correlation of JKAP with clinical features and inflammatory cytokines was non-obvious. For exacerbation severity, JKAP was the highest in mild exacerbation children, followed by moderate exacerbation children, and severe exacerbation children.

CONCLUSION

JKAP serves as a potential biomarker for asthmatic susceptibility, inflammation, exacerbation risk, and severity in children.

Asthma attacks in children are always preceded by poor asthma control: myth or maxim?

Some, but not all, asthma exacerbations in children are preceded by poor asthma control https://bit.ly/3muIy6h.

The economic burden of medical treatment of children with asthma in China

Background

At present, there are few studies on the economic burden and medical treatment of children with asthma in China. Thus this study aimed to investigate the economic burden of medical treatment of children with asthma in China.

Method

The 2015 China Medical Insurance Research Association (CHIRA) database was searched for patients with asthma from 0 to 14 years old. A cross-sectional study with cost analysis was conducted.

Results

The annual per capita direct medical cost was RMB 525 (US$75) related to asthma. Totaling 58% of the medical expenditure for asthma was covered by insurance in China, the majority of which were direct medical costs. Those that have the highest rates of using antibiotics were central China (100.0%), children aged 3 years and under (63.6%), as well as fourth-tier and fifth-tier cities (77.1%). Outpatient clinics (98.58% vs 1.42%, P < 0.01), tertiary hospitals (62.08% vs 37.92%, P < 0.01), and general hospitals (72.27% vs 27.73%, P < 0.01) were more often visited than the inpatient clinics, secondary and primary as well as the specialized clinics, respectively.

Conclusion

The economic burden of childhood asthma in China is relatively low, and the national medical insurance reduces their economic burden to a large extent. Abuse of antibiotics in treating asthma was found in China. There remain opportunities to strengthen the hierarchical medical system, reducing hospitalization and emergency visits, and ultimately reducing the economic burden of children with asthma.

Global Mapping of Research Trends on Interventions to Improve Health-Related Quality of Life in Asthma Patients

Globally, approximately 335 million people are being affected by asthma. Given that asthma is a chronic airway condition that cannot be cured, the disease negatively impacts physical health and results in losses of productivity of people experiencing asthma, leading to decrease in quality of life. This study aims at demonstrating the research trends worldwide and identifying the research gaps in interventions for improving quality of life of patients with asthma. Bibliometric approach and content analysis, which can objectively evaluate the productivity and research landscapes in this field, were utilized. In this study, we systematically quantified the development of research landscapes associated with interventions for improving quality of life of people experiencing asthma. Along with the gradual growth in the number of publications, these research topics have relatively expanded in recent years. While the understanding of the pathophysiology, diagnosis and treatment of asthma has been well-established, recent research has showed high interest in the control and management of asthma. Findings of this study suggest the need for more empirical studies in developing countries and further investigation into the effects of environment factors on asthma outcomes, as well as the economic burden of asthma.

A foreign body in the mediastinum as a cause of chronic cough in a 10-year-old child with asthma

Introduction: Chronic cough is a common problem faced by pediatricians, with a reported prevalence of 20% among preschoolers. It is also the most frequent symptom of asthma. Many causes of chronic cough may also be possible causes of asthma exacerbations.Case study: We describe a 10-year-old boy with asthma, which was admitted to the hospital with a persistent dry cough for five months. Initially, he was treated as an exacerbation of asthma; however, a subsequent chest X-ray identified a wire during the next hospitalization. Although the wire was not found during bronchoscopy, a CT scan located the wire in the mediastinum.Results: The patient required urgent thoracic surgery, ending with the extraction of a 3 cm-long metallic wire. The history revealed that he had choked on a pizza shortly before the onset of coughing: it is most likely that the foreign body had been aspirated, and that it may have originated from a metal brush used to clean the oven. However, it is difficult to determine whether the wire was originally aspirated into the airways or into the gastrointestinal tract; from the latter, it would have perforated either the bronchus or esophagus and migrated to the mediastinum.Conclusion: The symptoms associated with aspiration or ingestion of a foreign body in the upper aerodigestive tract can simulate other pediatric diseases, such as asthma, and delay the correct diagnosis. Our findings demonstrate that chronic cough in children with asthma is not always a result of exacerbation. Precise interviewing and correct interpretation of basic diagnostic testing may be key for setting an accurate diagnosis.

Risk of acute exacerbation between acetaminophen and ibuprofen in children with asthma

Background

Antipyretics are widely prescribed in pediatric practice. Some reports have mentioned that acetaminophen and non-steroid anti-inflammatory drugs may negatively affect asthma control by causing asthma exacerbation (AE). However, many confounding factors can also influence the risks. We assessed the impact of using acetaminophen or ibuprofen on AE in asthmatic children, especially those with strong risk factors.

Methods

We used the 2010 Taiwan National Health Insurance Research Database and identified 983 children with persistent asthma aged 1-5 years old; among them, 591 used acetaminophen alone and 392 used ibuprofen alone in 2010. Then, we analyzed the risk of AE over 52 weeks in the patients with and without severe AE in the previous year.

Results

The ibuprofen group had a higher risk of an emergency room (ER) visit or hospitalization for AE (odds ratio (OR) = 2.10, 95% confidence interval (CI) [1.17-3.76], P = 0.01). Among asthmatic children who had severe AE in the previous year, the risk of AE was higher in the ibuprofen group than in the acetaminophen group (OR = 3.28, 95% CI [1.30-8.29], P = 0.01), where as among those who did not, the risks of AE were similar between the acetaminophen and ibuprofen groups (OR = 1.52, 95% CI [0.71-3.25], P = 0.28).

Conclusions

Among young asthmatic children, use of ibuprofen was associated with a higher risk of AE than acetaminophen, if they had severe AE with ER visit or hospitalization in the previous year. Pediatricians should use antipyretics among children with asthma after a full evaluation of the risk.

Monocytes accumulate in the airways of children with fatal asthma

BACKGROUND

Activated T helper type 2 (Th2) cells are believed to play a pivotal role in allergic airway inflammation, but which cells attract and activate Th2 cells locally have not been fully determined. Recently, it was shown in an experimental human model of allergic rhinitis (AR) that activated monocytes rapidly accumulate in the nasal mucosa after local allergen challenge, where they promote recruitment of Th2 cells and eosinophils.

OBJECTIVE

To investigate whether monocytes are recruited to the lungs in paediatric asthma.

METHODS

Tissue samples obtained from children and adolescents with fatal asthma attack (n = 12), age-matched non-atopic controls (n = 9) and allergen-challenged AR patients (n = 8) were subjected to in situ immunostaining.

RESULTS

Monocytes, identified as CD68+S100A8/A9+ cells, were significantly increased in the lower airway mucosa and in the alveoli of fatal asthma patients compared with control individuals. Interestingly, cellular aggregates containing CD68+S100A8/A9+ monocytes obstructing the lumen of bronchioles were found in asthmatics (8 out of 12) but not in controls. Analysing tissue specimens from challenged AR patients, we confirmed that co-staining with CD68 and S100A8/A9 was a valid method to identify recently recruited monocytes. We also showed that the vast majority of accumulating monocytes both in the lungs and in the nasal mucosa expressed matrix metalloproteinase 10, suggesting that this protein may be involved in their migration within the tissue.

CONCLUSIONS AND CLINICAL RELEVANCE

Monocytes accumulated in the lungs of children and adolescents with fatal asthma attack. This finding strongly suggests that monocytes are directly involved in the immunopathology of asthma and that these pro-inflammatory cells are potential targets for therapy.

Safety and efficacy of tiotropium in children aged 1-5 years with persistent asthmatic symptoms: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Few studies have assessed the safety and efficacy of potential asthma medications in children younger than 5 years. We descriptively assessed the safety and efficacy of tiotropium, a long-acting anticholinergic drug, in children aged 1-5 years with persistent asthmatic symptoms.

METHODS

This exploratory 12-week, randomised, double-blind, placebo-controlled, parallel-group, phase 2/3, regulatory multicentre trial was done at 32 hospitals, clinics, and clinical research units in 11 countries in Asia, Europe, and North America. Children aged 1-5 years with at least a 6-month history of persistent asthmatic symptoms and a need for inhaled corticosteroids were eligible. Patients were randomly allocated using an interactive voice or web-based response system to receive once-daily tiotropium 2·5 μg, tiotropium 5 μg, or placebo as an add-on to inhaled corticosteroids with or without additional controller medication. Patients and investigators were masked to study group assignment. Tiotropium was given via the Respimat inhaler once daily as two puffs of 1·25 μg in the 2·5 μg group, two puffs of 2·5 μg in the 5 μg group, or two puffs of placebo. The primary outcomes were safety, which was assessed by comparing adverse events between the tiotropium and placebo groups, and efficacy, which was measured as the change in weekly mean combined daytime asthma symptom score from baseline to week 12. Statistical analyses of treatment effects were exploratory; although endpoints were defined, they were used for descriptive analyses only. The safety and primary analyses were done in all patients who received at least one dose of their assigned treatment. This study is registered with ClinicalTrials.gov (NCT01634113), and is completed.

FINDINGS

Between July 26, 2012, and Dec 4, 2014, 102 children were randomly assigned to the three treatment groups (36 to receive tiotropium 2·5 μg, 32 to receive tiotropium 5 μg, and 34 to receive placebo). 101 children completed the study and were included in the analyses. The changes in adjusted weekly mean combined daytime asthma symptom scores between baseline and week 12 were not significantly different between any of the groups. The adjusted mean difference between the tiotropium 2·5 μg group and placebo group was -0·080 (95% CI -0·312 to 0·152) and the difference between tiotropium 5 μg and placebo group was -0·048 (-0·292 to 0·195). Adverse events were less frequent with tiotropium treatment than with placebo (20 [56%] of 36 children with tiotropium 2·5 μg, 18 [58%] of 31 with tiotropium 5 μg, and 25 [74%] of 34 with placebo), although no formal statistical comparison between groups was performed. A greater proportion of children reported asthma exacerbations as adverse events in the placebo group (ten [29%] of 34) than in the tiotropium groups (five [14%] of 36 in the 2·5 μg group and two [6%] of 31 in the 5 μg group). Serious adverse events were reported in three patients (all of whom received placebo); no adverse events led to discontinuation of treatment or death.

INTERPRETATION

To our knowledge, our small study is the first to assess the safety and efficacy of tiotropium in children aged 1-5 years with persistent asthmatic symptoms. Tolerability of tiotropium was similar to that of placebo, which is consistent with previous findings in older populations. Although mean daytime asthma symptom scores were not significantly different between groups, tiotropium showed the potential to reduce asthma exacerbation risk compared with placebo. The findings of the study are limited by the small sample size and descriptive statistical analyses. Additional well powered trials are needed to further assess the safety and efficacy of tiotropium in young children.

FUNDING

Boehringer Ingelheim.

Exposure to NO2, CO, and PM2.5 is linked to regional DNA methylation differences in asthma

Background

DNA methylation of CpG sites on genetic loci has been linked to increased risk of asthma in children exposed to elevated ambient air pollutants (AAPs). Further identification of specific CpG sites and the pollutants that are associated with methylation of these CpG sites in immune cells could impact our understanding of asthma pathophysiology. In this study, we sought to identify some CpG sites in specific genes that could be associated with asthma regulation (Foxp3 and IL10) and to identify the different AAPs for which exposure prior to the blood draw is linked to methylation levels at these sites. We recruited subjects from Fresno, California, an area known for high levels of AAPs. Blood samples and responses to questionnaires were obtained (n = 188), and in a subset of subjects (n = 33), repeat samples were collected 2 years later. Average measures of AAPs were obtained for 1, 15, 30, 90, 180, and 365 days prior to each blood draw to estimate the short-term vs. long-term effects of the AAP exposures.

Results

Asthma was significantly associated with higher differentially methylated regions (DMRs) of the Foxp3 promoter region (p = 0.030) and the IL10 intronic region (p = 0.026). Additionally, at the 90-day time period (90 days prior to the blood draw), Foxp3 methylation was positively associated with NO₂, CO, and PM_2.5 exposures (p = 0.001, p = 0.001, and p = 0.012, respectively). In the subset of subjects retested 2 years later (n = 33), a positive association between AAP exposure and methylation was sustained. There was also a negative correlation between the average Foxp3 methylation of the promoter region and activated Treg levels (p = 0.039) and a positive correlation between the average IL10 methylation of region 3 of intron 4 and IL10 cytokine expression (p = 0.030).

Conclusions

Short-term and long-term exposures to high levels of CO, NO₂, and PM_2.5 were associated with alterations in differentially methylated regions of Foxp3. IL10 methylation showed a similar trend. For any given individual, these changes tend to be sustained over time. In addition, asthma was associated with higher differentially methylated regions of Foxp3 and IL10.

Electronic supplementary material

The online version of this article (10.1186/s13148-017-0433-4) contains supplementary material, which is available to authorized users.

Adolescent girls with asthma have worse asthma control and health-related quality of life than boys-A population based study

BACKGROUND

Population-based studies investigating health-related quality of life (HRQoL) among asthmatic adolescents are rare. Further, among subjects with asthma, HRQoL may be affected by asthma control and severity.

AIM

To investigate HRQoL in relation to asthma control and asthma severity among adolescents.

METHOD

As a part of the population-based OLIN pediatric study, 266 adolescents with current asthma (14-15 yr) were identified. N = 247 completed the DISABKIDS HRQoL asthma module, including the domains impact and worry. The Asthma Control Test (ACT) was used and a disease severity score was calculated based on symptoms and medicine use.

RESULTS

The prevalence of current asthma was 11%. Well-controlled asthma was reported by 15% of the adolescents, and 53% had partly controlled asthma. The prevalence of uncontrolled asthma was significantly higher among girls than boys (38% vs 25%), and girls also reported lower HRQoL scores. There was a fairly strong correlation between the ACT and DISABKIDS scores. Independent risk factors for low HRQoL impact (a score <67) were female sex (OR 4.66, 95%CI 1.82-9.54) and decreased ACT scores (1.38, 1.18-1.62). Risk factors for low HRQoL worry (a score <70) were female sex (3.33, 1.41-7.86), decreased ACT scores (1.35, 1.16-1.57), severe asthma (6.23, 1.46-16.50), and having current eczema (2.68, 1.00-7.24).

CONCLUSION

Only a minority of the asthmatic adolescents reported well-controlled asthma, and poor asthma control and female sex were risk factors for low HRQoL. Our results demonstrate that evaluation of asthma control is of great importance for asthma management.

Cross-Disciplinary Consultancy to Enhance Predictions of Asthma Exacerbation Risk in Boston

This paper continues an initiative conducted by the International Society for Disease Surveillance with funding from the Defense Threat Reduction Agency to connect near-term analytical needs of public health practice with technical expertise from the global research community. The goal is to enhance investigation capabilities of day-to-day population health monitors. A prior paper described the formation of consultancies for requirements analysis and dialogue regarding costs and benefits of sustainable analytic tools. Each funded consultancy targets a use case of near-term concern to practitioners. The consultancy featured here focused on improving predictions of asthma exacerbation risk in demographic and geographic subdivisions of the city of Boston, Massachusetts, USA based on the combination of known risk factors for which evidence is routinely available. A cross-disciplinary group of 28 stakeholders attended the consultancy on March 30-31, 2016 at the Boston Public Health Commission. Known asthma exacerbation risk factors are upper respiratory virus transmission, particularly in school-age children, harsh or extreme weather conditions, and poor air quality. Meteorological subject matter experts described availability and usage of data sources representing these risk factors. Modelers presented multiple analytic approaches including mechanistic models, machine learning approaches, simulation techniques, and hybrids. Health department staff and local partners discussed surveillance operations, constraints, and operational system requirements. Attendees valued the direct exchange of information among public health practitioners, system designers, and modelers. Discussion finalized design of an 8-year de-identified dataset of Boston ED patient records for modeling partners who sign a standard data use agreement.

The Danish National Database for Asthma: establishing clinical quality indicators

Asthma is one of the most common chronic diseases worldwide affecting more than 300 million people. Symptoms are often non-specific and include coughing, wheezing, chest tightness, and shortness of breath. Asthma may be highly variable within the same individual over time. Although asthma results in death only in extreme cases, the disease is associated with significant morbidity, reduced quality of life, increased absenteeism, and large costs for society. Asthma can be diagnosed based on report of characteristic symptoms and/or the use of several different diagnostic tests. However, there is currently no gold standard for making a diagnosis, and some degree of misclassification and inter-observer variation can be expected. This may lead to local and regional differences in the treatment, monitoring, and follow-up of the patients. The Danish National Database for Asthma (DNDA) is slated to be established with the overall aim of collecting data on all patients treated for asthma in Denmark and systematically monitoring the treatment quality and disease management in both primary and secondary care facilities across the country. The DNDA links information from population-based disease registers in Denmark, including the National Patient Register, the National Prescription Registry, and the National Health Insurance Services register, and potentially includes all asthma patients in Denmark. The following quality indicators have been selected to monitor trends: first, conduction of annual asthma control visits, appropriate pharmacological treatment, measurement of lung function, and asthma challenge testing; second, tools used for diagnosis in new cases; and third, annual assessment of smoking status, height, and weight measurements, and the proportion of patients with acute hospital treatment. The DNDA will be launched in 2016 and will initially include patients treated in secondary care facilities in Denmark. In the nearby future, the database aims to include asthma diagnosis codes and clinical data registered by general practitioners and specialised practitioners as well.

Effects of montelukast on M2-related cytokine and chemokine in M2 macrophages

BACKGROUND/PURPOSE

Asthma is a chronic airway inflammatory disease mediated by T-helper (Th)2 cells. Montelukast (trade name Singulair) is a cysteinyl leukotriene receptor antagonist used for asthma treatment. Mirroring Th1-Th2 polarization, two distinct states of macrophages have been recognized: the classically activated (M1) macrophages and the alternatively activated (M2) macrophages. M2 polarization is known to be a response to the Th2 cytokines; however, the effects of montelukast on M2 macrophages have not been well characterized. The aim of the present study was to investigate the effects of montelukast on the expression of cytokines and chemokines in M2-like macrophages, and to explore possible intracellular signaling pathways.

METHODS

The human monocytic leukemia cell line THP-1 and human monocytes from healthy donors were cultured with interleukin-4 for M2 polarization, and then the cells were pretreated with or without montelukast before lipopolysaccharide (LPS) stimulation. Supernatants were collected to determine interleukin-10, I-309/CCL1, and MDC/CCL22 levels by enzyme-linked immunosorbent assay. Intracellular signaling was investigated using nuclear factor (NF)-κB inhibitors, mitogen-activated protein kinase (MAPK) inhibitors, and western blot analysis.

RESULTS

LPS-induced interleukin-10 and I-309/CCL1 expression was significantly suppressed by montelukast in THP-1-derived and human monocyte-derived M2 macrophages after LPS stimulation. MDC/CCL22 expression was only significantly suppressed by montelukast in THP-1-derived M2 macrophages after 48 hours of incubation. In western blot analysis, montelukast was able to suppress LPS-induced MAPK-phospho-p38 and NF-κB-phospho-p65 expression.

CONCLUSION

Montelukast suppressed LPS-induced M2-related cytokines and chemokines in alternatively activated macrophages, and the effects might be mediated through the MAPK-p38 and NF-κB-p65 pathways.