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Mosnaim G, Carrasquel M, Snedden M, Oppenheimer J, Lang D, Rathkopf M. Patient-Reported Outcomes in Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2562-2572. [PMID: 38796101 DOI: 10.1016/j.jaip.2024.04.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/11/2024] [Accepted: 04/19/2024] [Indexed: 05/28/2024]
Abstract
Food and Drug Administration's Center for Drug Evaluation and Research defines patient-reported outcomes as "any report of the status of a patient's health condition, health behavior, or experience with healthcare that comes directly form the patient, without interpretation of the patient's response by a clinician or anyone else." Validated patient-reported outcome measures are used extensively in pediatric and adult asthma across clinical and research settings to assess the impact of treatments on patient outcomes over time. This work aims to review some of the most commonly used asthma patient-reported outcomes across the following criteria: validity, reliability, responsiveness, time to complete, ease of administration, target population, recall period, scoring method, availability in different languages, use in clinical practice or research settings, licensing requirements, and cost of use.
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Affiliation(s)
- Giselle Mosnaim
- Division of Allergy & Immunology, Department of Medicine, Endeavor Health, Glenview, Ill.
| | - Michelle Carrasquel
- Division of Allergy & Immunology, Department of Medicine, Endeavor Health, Glenview, Ill
| | - Madeline Snedden
- Division of Allergy & Immunology, Department of Medicine, Endeavor Health, Glenview, Ill
| | - John Oppenheimer
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ
| | - David Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Melinda Rathkopf
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga
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Valkenborghs SR, Wood LG, Callister R, Upham JW, Grainge CL, Anderson S, Williams LM, McLoughlin RF, Williams EJ, Scott HA. Effects of Moderate- Versus Vigorous-Intensity Exercise Training on Asthma Outcomes in Adults. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2744-2753.e8. [PMID: 38901614 DOI: 10.1016/j.jaip.2024.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 05/20/2024] [Accepted: 06/09/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND The therapeutic effects of exercise have prompted calls for it to be embedded into standard asthma care, but evidence informing the optimal exercise intensity is lacking. OBJECTIVE This study aimed to compare the effects of moderate- and vigorous-intensity aerobic exercise training on asthma outcomes and inflammation. METHODS This was a 12-week randomized controlled trial in 46 adults with asthma randomized to either (1) 45-minute moderate-intensity exercise training 3 times/wk, (2) 30-minute vigorous-intensity exercise training 3 times/wk, or (3) the control group. Asthma-related quality of life (AQLQ), asthma control (ACQ), cardiorespiratory fitness, body composition, and airway and systemic inflammation were assessed before and after the intervention. RESULTS Forty-one participants completed the study (89% retention). The moderate-intensity group had a statistically and clinically significant improvement in AQLQ (0.63 [0.33-0.93], P < .001) and ACQ (-0.51 [-0.83 to -0.19], P = .003) relative to control. The vigorous-intensity group had a statistically, but not clinically, significant improvement in AQLQ (0.46 [0.14-0.80], P = .007) and ACQ (-0.36 [-0.69 to -0.02], P = .040) relative to control. After moderate-intensity training, there was a reduction in sputum macrophage (-1341 [-2491 to -191] × 104/mL, P = .024) and lymphocyte (-114 [-220 to -8] × 104/mL, P = .036) counts relative to control. A reduction in android fat mass, but not a change in fitness, was associated with improved AQLQ (rs = -0.341, P = .030) and reduced sputum IL-6 (rs = 0.422, P = .013). CONCLUSIONS Our findings suggest that both moderate-intensity and vigorous-intensity aerobic exercise training are associated with improvements in clinical asthma outcomes and, therefore, both intensities could be recommended as an adjuvant asthma therapy.
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Affiliation(s)
- Sarah R Valkenborghs
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, NSW, Australia; Active Living Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Lisa G Wood
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, NSW, Australia; Immune Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Robin Callister
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, NSW, Australia; Active Living Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - John W Upham
- Translational Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Christopher L Grainge
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Sophie Anderson
- School of Environmental and Life Sciences, The University of Newcastle, Ourimbah, NSW, Australia
| | - Lily M Williams
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, NSW, Australia; Immune Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Rebecca F McLoughlin
- School of Nursing and Midwifery, The University of Newcastle, Callaghan, NSW, Australia; Asthma and Breathing Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia; National Health and Medical Research Council, Centre of Excellence in Treatable Traits, New Lambton Heights, NSW, Australia
| | - Evan J Williams
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, NSW, Australia; Immune Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Hayley A Scott
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, NSW, Australia; Immune Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.
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Busby J, Menon S, Martin N, Lipworth J, Zhang R, Burhan H, Brown T, Chaudhuri R, Gore R, Jackson DJ, Naveed S, Pantin T, Pfeffer PE, Patel M, Patel PH, Rupani H, Heaney LG. Clinical and Economic Burden of Severe Asthma With Low Blood Eosinophil Counts. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2785-2797. [PMID: 39032830 DOI: 10.1016/j.jaip.2024.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 07/05/2024] [Accepted: 07/10/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Type 2 low-severe asthma phenotype is often a result of corticosteroid-overtreated type 2 disease owing to persistent symptoms, often unrelated to asthma and unlikely to respond to high-dose corticosteroid treatment. OBJECTIVE This study aimed to characterize patients with severe asthma with low eosinophil counts (<300 cells/μL) and describe their disease burden and treatment across health care settings in the United Kingdom. METHODS A retrospective cohort study of patients with severe asthma using linked Clinical Practice Research Datalink (CPRD) Aurum-Hospital Episode Statistics (HES) and UK Severe Asthma Registry (UKSAR) data indexed patients according to the latest blood eosinophil count (BEC). Clinical characteristics, treatment patterns, outcomes, and health care resource use were described by baseline BEC (≤150 and >150 to <300 cells/μL). RESULTS Analysis included 701 (CPRD-HES) and 1,546 (UKSAR) patients; 60.5% and 59.4% had BECs 150 cells/μL or less at baseline, respectively. Across BEC groups, the proportion with uncontrolled asthma (two or more exacerbations) at follow-up (12 months after the index) was 5.4% in CPRD-HES and 45.2% in UKSAR. Maintenance oral corticosteroid use remained high across BEC groups (CPRD-HES: 29.4%; UKSAR: 51.7%), symptom control remained poor (>200 μg short-acting β2 agonist or >500 μg terbutaline/d in CPRD-HES: 48.8%; median Asthma Control Questionnaire-6 score in UKSAR: 2.0 [range, 1.0-3.3]). Health care resource use was similar across BEC groups. CONCLUSIONS Most patients managed in primary care experienced infrequent exacerbations, whereas UKSAR patients had frequent exacerbations. Large proportions of both patient groups had poor symptom control and continued to receive high levels of maintenance oral corticosteroids, increasing the risk of corticosteroid-induced morbidity. These data highlight the need for rigorous assessment of underlying disease pathology to guide appropriate treatment.
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Affiliation(s)
- John Busby
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Shruti Menon
- Medical and Scientific Affairs, AstraZeneca UK, London, United Kingdom
| | - Neil Martin
- BioPharmaceuticals Medical, AstraZeneca, Cambridge, United Kingdom; University of Leicester, Respiratory Sciences, Leicester, United Kingdom
| | - Joe Lipworth
- Medical and Scientific Affairs, AstraZeneca UK, London, United Kingdom
| | - Ruiqi Zhang
- Medical and Scientific Affairs, AstraZeneca UK, London, United Kingdom
| | - Hassan Burhan
- Respiratory Medicine, Royal Liverpool Hospital, Liverpool, United Kingdom
| | - Thomas Brown
- Portsmouth Hospitals University NHS Trust, Portsmouth, United Kingdom
| | - Rekha Chaudhuri
- Respiratory Medicine, Gartnavel General Hospital, School of Infection & Immunity, University of Glasgow, Glasgow, United Kingdom
| | - Robin Gore
- Respiratory Medicine, Addenbrookes Hospital, Cambridge, United Kingdom
| | - David J Jackson
- Guy's Severe Asthma Centre, King's Centre for Lung Health, King's College London, London, United Kingdom
| | - Shamsa Naveed
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Thomas Pantin
- Respiratory Medicine, Wythenshawe Hospital, Manchester, United Kingdom
| | - Paul E Pfeffer
- St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Mitesh Patel
- Respiratory Medicine, Derriford Hospital, Plymouth, United Kingdom
| | - Pujan H Patel
- Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Hitasha Rupani
- University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Liam G Heaney
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom.
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Walters GI, Reilly C, Le Moual N, Huntley CC, Hussein H, Marsh J, Bahron A, Krishna MT, Mansur AH. Asthma control in severe asthma and occupational exposures to inhalable asthmagens. BMJ Open Respir Res 2024; 11:e001943. [PMID: 39349306 PMCID: PMC11448311 DOI: 10.1136/bmjresp-2023-001943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 05/21/2024] [Indexed: 10/02/2024] Open
Abstract
INTRODUCTION Work-related asthma accounts for ≥25% of asthma in working-age populations, though the relationship between work exposures and symptoms is frequently missed, leading to poor health and employment outcomes. We hypothesised that inhalable exposures at work are associated with poor asthma control in severe asthma (SA). METHODS We searched the Birmingham (UK) Regional NHS SA Service clinical database (n=1453 records; 1 March 2004 to 1 March 2021) and undertook a cross-sectional study using baseline data collected at diagnosis. We included all employed patients aged 16-64 with documented current occupation (n=504), and collected socio-demographic, general health and asthma-specific data, including Asthma Control Questionnaire 7 (ACQ7) score. The Occupational Asthma Specific Job-Exposure Matrix (OAsJEM) was employed to determine the likelihood of exposure to respiratory sensitisers, irritants, cleaning agents and detergents; associations between exposures and ACQ7 were investigated using binary and multinomial regression. RESULTS Frequently reported occupations were care assistants (7%) and nurses (6%); 197/504 (39%) patients were exposed to an asthmagen, including respiratory sensitisers (30%), airway irritants (38%) and cleaning products/disinfectants (29%). ACQ7 score was available for 372/504 (74%) patients, of whom 14% had adequate control (ACQ7=0-1.5). After adjustment for major confounders there were no significant associations between inhaled asthmagens and ACQ7 score (either as binary or multinomial outcomes). CONCLUSION JEM-determined workplace exposures to inhaled asthmagens are not associated with asthma control in SA; 29-39% of patients may have current exposure to workplace asthmagens. Routine collection of lifetime occupational data including current job role and level of exposure, in the national asthma registry, would give further insights into this relationship.
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Affiliation(s)
- Gareth I Walters
- Occupational Lung Disease Service, Birmingham Heartlands Hospital, Birmingham, UK
- Institute of Applied Heath Research, University of Birmingham, Birmingham, UK
| | | | | | - Christopher C Huntley
- Occupational Lung Disease Service, Birmingham Heartlands Hospital, Birmingham, UK
- Institute of Applied Heath Research, University of Birmingham, Birmingham, UK
| | - Hanan Hussein
- Severe Asthma Service, Birmingham Heartlands Hospital, Birmingham, UK
| | - Julie Marsh
- Severe Asthma Service, Birmingham Heartlands Hospital, Birmingham, UK
| | - Ali Bahron
- Severe Asthma Service, Birmingham Heartlands Hospital, Birmingham, UK
| | | | - Adel H Mansur
- Birmingham Regional Severe Asthma Service, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Ageing and Inflammation, University of Birmingham, Birmingham, UK
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Ishisaka Y, Ankam J, Feldman J, Busse P, Wisnivesky JP, Federman AD. Asthma beliefs and overuse of short-acting beta-adrenergic receptor agonists among older adults. J Asthma 2024:1-8. [PMID: 39258932 DOI: 10.1080/02770903.2024.2403742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 09/02/2024] [Accepted: 09/09/2024] [Indexed: 09/12/2024]
Abstract
OBJECTIVE Short-acting Beta-adrenergic Receptor Agonists (SABA) carry a risk of worse asthma outcomes when overused. Beliefs about asthma controller medications are associated with medication-taking behaviors in older adults, but the association of medication beliefs with SABA use has not been previously examined. We aimed to investigate the association of asthma and controller medication beliefs with SABA use among older patients with asthma. METHODS We performed a cross-sectional analysis of data on adults ≥ 60 years old with moderate to severe asthma in New York City, NY (n = 234). SABA overuse was defined as the average of ≥1 inhalation per day and controller medication adherence as ≥80% of expected inhalations, measured electronically. Illness and medication beliefs were measured using the Brief-Illness Perception Questionnaire and Beliefs about Medications Questionnaire, respectively. The associations of medication-taking behaviors with beliefs were examined in multivariable logistic regression models. RESULTS The mean age was 67.6 ± 6.5 years, 84% were female, 26% were Black and 53% were Hispanic. 35% of participants overused SABA and 21% had adequate controller medication adherence. Overuse of SABA was not significantly associated with controller medication beliefs (Necessity: odds ratio [OR] 1.04, 95% confidence interval [CI] [0.97-1.12], p = 0.28, Concerns: OR 0.95 [95% CI 0.88, 1.03], p = 0.23) or asthma beliefs (OR 1.06 [95% CI 0.99, 1.15], p = 0.11). SABA overuse was also not significantly associated with controller medication adherence (OR 2.20 [95% CI 0.88, 5.51], p = 0.09). CONCLUSIONS SABA overuse was common among older adults with asthma and was not significantly associated with asthma controller medication or illness beliefs.
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Affiliation(s)
- Yoshiko Ishisaka
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside and West, New York, NY, USA
| | - Jyoti Ankam
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan Feldman
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Paula Busse
- Department of Medicine, Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Mizumura K, Gon Y, Harada N, Yamada S, Fukuda A, Ozoe R, Maruoka S, Abe S, Takahashi K, Tanaka A, Sagara H, Akamatsu T, Shirai T, Masaki K, Fukunaga K, Kobayashi K, Nagase H, Miyahara N, Kanehiro A, Kitamura N, Sugihara N, Kumasawa F, Terada-Hirashima J, Hojo M, Chibana K, Tagaya E. Predicting dupilumab effectiveness with Type-2 biomarkers: A real-world study of severe asthma. Allergol Int 2024:S1323-8930(24)00087-X. [PMID: 39277433 DOI: 10.1016/j.alit.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 07/29/2024] [Accepted: 08/11/2024] [Indexed: 09/17/2024] Open
Abstract
BACKGROUND The therapeutic effectiveness of dupilumab for severe asthma in real-world settings is yet to be prospectively investigated across multiple institutions, and uncertainties persist regarding predictive factors for its effectiveness. We aimed to assess the effectiveness of dupilumab and identify predictors of its effectiveness in real-world settings using two type-2 biomarkers: FeNO concentration and blood eosinophil count. METHODS This prospective multicenter study included 103 patients with severe asthma. Exacerbations and respiratory functions were monitored for 24 weeks. Asthma control was evaluated using the Asthma Control Questionnaire-5. Clinical symptoms and their impact on cough and sputum were assessed using the Cough and Sputum Assessment Questionnaire (CASA-Q). Subgroup analyses of type-2 biomarkers were conducted based on FeNO levels and blood eosinophil counts at baseline. RESULTS Treatment with dupilumab led to a reduction in exacerbations and enhancement in asthma control, FEV1, and CASA-Q scores. FEV1 improvement was correlated with enhancement in the sputum domain of the CASA-Q. Patients exhibiting elevated FeNO levels and blood eosinophil counts demonstrated more significant enhancements in FEV1. CASA-Q sputum domain scores were significantly higher in the group with elevated eosinophil counts. Regression analysis revealed that FeNO levels and blood eosinophil counts are significant predictors of FEV1 improvement, with blood eosinophil counts also predicting sputum improvement in patients treated with dupilumab. CONCLUSIONS Type-2 biomarkers may act as indicators of improvement in FEV1 and sputum outcomes among patients with severe asthma undergoing dupilumab treatment in real-world settings.
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Affiliation(s)
- Kenji Mizumura
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan.
| | - Yasuhiro Gon
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Norihiro Harada
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Shiho Yamada
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Asami Fukuda
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Ryosuke Ozoe
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Shuichiro Maruoka
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Sumiko Abe
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhisa Takahashi
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Akihiko Tanaka
- Division of Respiratory Medicine and Allergology, Department of Medicine, School of Medicine, Showa University, Tokyo, Japan
| | - Hironori Sagara
- Division of Respiratory Medicine and Allergology, Department of Medicine, School of Medicine, Showa University, Tokyo, Japan
| | - Taisuke Akamatsu
- Department of Respiratory Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Toshihiro Shirai
- Department of Respiratory Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Katsunori Masaki
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Koichi Fukunaga
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Konomi Kobayashi
- Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Hiroyuki Nagase
- Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Nobuaki Miyahara
- Department of Medical Technology, Okayama University Academic Field of Health Sciences, Okayama, Japan
| | - Arihiko Kanehiro
- Social Medical Corporation Foundation of St. Francis Himeji St. Mary's Hospital, Hyogo, Japan
| | | | | | - Fumio Kumasawa
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan; Division of Respiratory Medicine, Akabane Central General Hospital, Tokyo, Japan
| | - Junko Terada-Hirashima
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masayuki Hojo
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kazuyuki Chibana
- Department of Pulmonary Medicine and Clinical Immunology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Etsuko Tagaya
- Department of Respiratory Medicine, Tokyo Women's Medical University, Tokyo, Japan
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Chan AHY, Leong P, Politis J, McDonald VM, Bardin P. Patient-reported outcomes: missing in asthma remission. THE LANCET. RESPIRATORY MEDICINE 2024; 12:665-666. [PMID: 39128472 DOI: 10.1016/s2213-2600(24)00242-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 07/22/2024] [Indexed: 08/13/2024]
Affiliation(s)
- Amy Hai Yan Chan
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand.
| | - Paul Leong
- Monash Lung Sleep Allergy and Immunology and School of Clinical Sciences, Monash Health and Hudson Institute of Medical Research, Monash University, Melbourne, VIC, Australia
| | - John Politis
- Monash Lung Sleep Allergy and Immunology and School of Clinical Sciences, Monash Health and Hudson Institute of Medical Research, Monash University, Melbourne, VIC, Australia
| | - Vanessa M McDonald
- Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Philip Bardin
- Monash Lung Sleep Allergy and Immunology and School of Clinical Sciences, Monash Health and Hudson Institute of Medical Research, Monash University, Melbourne, VIC, Australia
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Oh SH, Rhee CK, Bae EJ, Ku H. Cost-effectiveness analysis of dupilumab among patients with uncontrolled severe asthma using LIBERTY ASTHMA QUEST Korean data. HEALTH ECONOMICS REVIEW 2024; 14:67. [PMID: 39186143 PMCID: PMC11346198 DOI: 10.1186/s13561-024-00532-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 07/03/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND A sub-analysis of the Korean population in the LIBERTY ASTHMA QUEST trial (NCT02414854) revealed that dupilumab effectively treated severe uncontrolled asthma. This study aimed to assess the cost-effectiveness of add-on therapy with dupilumab to background therapy in patients ≥ 12 years of age with uncontrolled severe asthma compared to that of background therapy in South Korea. METHODS The cost-effectiveness analysis was conducted using a Markov model over a lifetime from the Korean healthcare system perspective. Clinical efficacy and utility weights were obtained from post-hoc analyses of the Korean population in the QUEST trial. Data on the costs and treatment setting of exacerbation in a real-world setting were retrospectively collected using the administrative medical database from a single tertiary hospital. RESULTS The base-case results indicated that add-on dupilumab therapy increases costs ($112,924 for add-on dupilumab versus $29,545 for background therapy alone). However, add-on dupilumab increased quality-adjusted life years (QALYs, 8.03 versus 3.93, respectively), with fewer events of severe exacerbations per patient compared to using the background therapy alone (17.920 versus 19.911, respectively). The incremental cost-effectiveness ratio was $20,325 per QALY. Various sensitivity analyses supported the robustness of the base-case results. Probabilistic sensitivity analysis showed that the probability of add-on dupilumab being cost-effective was 87% at a threshold willingness-to-pay of $26,718 (KRW 35 million) per QALY gained. CONCLUSIONS Dupilumab is cost-effective for adolescents and adults with uncontrolled severe asthma in South Korea. Our study provides evidence to support clinicians and policymakers in making informed decisions for severe asthma management.
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Affiliation(s)
- Sung-Hee Oh
- BK21 FOUR Community-Based Intelligent Novel Drug Discovery Education Unit, College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, 41566, Republic of Korea
| | - Chin Kook Rhee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | | | - Hyemin Ku
- NDnex, Saebitgongwon-ro 67, Gwangmyeong-si, Gyeonggi-do, 14348, Republic of Korea.
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de Lima FF, Dos Santos JMB, Lunardi AC, de Oliveira JM, Freitas PD, Kim FS, Agondi RC, Carvalho-Pinto RM, Furlanetto KC, Carvalho CRF. Physical Activity and Sedentary Behavior as Treatable Traits for Clinical Control in Moderate-to-Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2047-2055. [PMID: 38492665 DOI: 10.1016/j.jaip.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/21/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Physical activity and sedentary behavior are treatable traits that may impact asthma control in distinct manners, but this impact remains poorly understood. OBJECTIVE To evaluate the influence of physical activity and sedentary behavior on clinical control in adults with moderate-to-severe asthma. METHODS This cross-sectional, multicentric study included 426 individuals with moderate-to-severe asthma. Assessments included physical activity and sedentary time (actigraphy), clinical asthma control (Asthma Control Questionnaire [ACQ]), quality of life (Asthma Quality of Life Questionnaire), anxiety and depression symptoms (Hospital Anxiety and Depression Scale), anthropometric data, and lung function. Participants were grouped according to physical activity levels and sedentary behavior. RESULTS Participants who walked ≥7500 steps/day presented better ACQ scores than those who walked <7500 steps/day (P < .05), independent of sedentary status. The percentage of patients with controlled asthma was higher in the active/sedentary (43.9%) and active/nonsedentary (43.8%) groups than in the inactive/sedentary (25.4%) and inactive/nonsedentary (23.9%) groups (P < .02). The likelihood of having uncontrolled asthma according to the treatable traits of physical inactivity (odds ratio [95% confidence interval]: 2.36 [1.55-3.59]), higher anxiety (2.26 [1.49-3.42]), and depression symptoms (1.95 [1.28-2.95]) was significant (P ≤ .002). Obesity and sedentary time were not associated with asthma control. CONCLUSIONS Our results show that ≥7500 steps/day is associated with better asthma control independent of sedentary time in adults with moderate-to-severe asthma. Physical inactivity, anxiety, and depression symptoms are associated with higher odds of uncontrolled asthma. These results suggest that interventions should mainly focus on increasing physical activity rather than reducing sedentary time.
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Affiliation(s)
- Fabiano F de Lima
- Department of Physical Therapy, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Juliana M B Dos Santos
- Department of Physical Therapy, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Adriana C Lunardi
- Department of Physical Therapy, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Joice M de Oliveira
- Biological and Health Sciences Center, UNOPAR Pitágoras University, Londrina, Brazil; Laboratory of Research in Pulmonary Physiotherapy, State University of Londrina (UEL), Londrina, Brazil
| | - Patrícia D Freitas
- Department of Physical Therapy, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Fabiana S Kim
- Department of Physical Therapy, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Rosana Câmara Agondi
- Clinical Immunology and Allergy Division, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Regina M Carvalho-Pinto
- Pulmonary Division, Heart Institute (InCor), School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Karina C Furlanetto
- Biological and Health Sciences Center, UNOPAR Pitágoras University, Londrina, Brazil; Laboratory of Research in Pulmonary Physiotherapy, State University of Londrina (UEL), Londrina, Brazil
| | - Celso R F Carvalho
- Department of Physical Therapy, School of Medicine, University of São Paulo, São Paulo, Brazil.
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10
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Pfeffer PE, Brown T, Chaudhuri R, Faruqi S, Gore R, Heaney LG, Mansur AH, Pantin T, Patel M, Rupani H, Siddiqui S, Vyas A, Busby J. Impact of comorbidities on EQ-5D quality-of-life index in severe asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100286. [PMID: 39071731 PMCID: PMC11277382 DOI: 10.1016/j.jacig.2024.100286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 03/10/2024] [Accepted: 04/05/2024] [Indexed: 07/30/2024]
Abstract
Background Severe asthma pathology encompasses a wide range of pulmonary and extrapulmonary treatable traits with a high prevalence of comorbidities. Although asthma-specific health-related quality-of-life measures are most sensitive to changes in asthma control, generic measures, such as EQ-5D-5L (EuroQol 5-Dimension 5-Level questionnaire), are potentially better for capturing the impact of comorbidities. Objective We sought to examine the impact of pulmonary and extrapulmonary treatable traits on quality of life at initial severe asthma assessment, and to compare the characteristics of those patients whose quality of life does and does not improve during follow-up at severe asthma centers. Methods Patients' characteristics at baseline assessment within the UK Severe Asthma Registry were compared by EQ-5D-5L utility index quartile. Patients with follow-up review data were stratified by change in EQ-5D-5L utility index from baseline to follow-up, and characteristics similarly examined. Results Patients in the quartiles with worst dysutility at baseline were observed to exhibit more treatable traits and in particular extrapulmonary traits associated with cumulative systemic corticosteroids, including obesity, anxiety/depression, and osteoporosis. In those patients whose quality of life improved over follow-up, a reduction in exacerbations, uncontrolled symptoms, and requirement for maintenance oral corticosteroids were observed. Conclusions Both pulmonary and extrapulmonary treatable traits are important determinants of quality of life in severe asthma. Comorbidities associated with cumulative systemic corticosteroid exposure are particularly associated with worse quality of life, emphasizing the importance of early identification and management of severe asthma before comorbidities develop.
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Affiliation(s)
- Paul E. Pfeffer
- Barts Health NHS Trust, London, United Kingdom
- Queen Mary University of London, London, United Kingdom
| | - Thomas Brown
- Portsmouth Hospitals University NHS Trust, Portsmouth, United Kingdom
| | - Rekha Chaudhuri
- Gartnavel General Hospital and University of Glasgow, Glasgow, United Kingdom
| | - Shoaib Faruqi
- Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
| | - Robin Gore
- Addenbrookes Hospital, Cambridge, United Kingdom
| | | | - Adel H. Mansur
- University Hospitals Birmingham NHS Trust, Birmingham, United Kingdom
- University of Birmingham, Birmingham, United Kingdom
| | | | | | - Hitasha Rupani
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Salman Siddiqui
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Aashish Vyas
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - John Busby
- Centre for Public Health, Queen’s University Belfast, Belfast, United Kingdom
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11
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Tajiri T, Suzuki M, Nishiyama H, Ozawa Y, Kurokawa R, Ito K, Fukumitsu K, Mori Y, Kanemitsu Y, Fukuda S, Uemura T, Ohkubo H, Takemura M, Maeno K, Ito Y, Oguri T, Iwasaki S, Niimi A. Efficacy of dupilumab for severe chronic rhinosinusitis with nasal polyps and asthma: A prospective study. Ann Allergy Asthma Immunol 2024:S1081-1206(24)00422-8. [PMID: 38972450 DOI: 10.1016/j.anai.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 06/28/2024] [Accepted: 07/01/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Dupilumab exerts clinical effects, including improved sinus opacification, olfactory function, and quality of life, in patients with severe chronic rhinosinusitis with nasal polyps (CRSwNPs). Meanwhile, only a few studies have reported its effects on nasal airway resistance and olfactory function, particularly in the Japanese population. Predictors of response remain unclear. OBJECTIVE To assess the comprehensive efficacy and therapeutic response to dupilumab in patients with severe CRSwNP with comorbid asthma. METHODS In 16 adult patients with severe CRSwNP with comorbid asthma, the efficacy of 48-week dupilumab treatment, including olfactory function measured by a T&T olfactometer, nasal airway resistance measured by rhinomanometry, nasal polyp score, Lund-Mackay computed tomography score, and 22-item Sinonasal Outcome Test (SNOT-22), was assessed. Regarding asthma, the annualized rate of exacerbations, 7-item Asthma Control Questionnaire (ACQ-7), and spirometry were assessed. Treatment responsiveness was analyzed. RESULTS With 48-week dupilumab treatment, olfactory function, nasal airway resistance, nasal polyp score, Lund-Mackay computed tomography score, and SNOT-22 scores improved significantly. Regarding comorbid asthma, the annualized rate of exacerbations decreased, and ACQ-7 scores and lung function improved significantly. According to the European Position Paper on Rhinosinusitis and Nasal Polyps 2020/European Forum for Research and Education in Allergy and Airway Diseases criteria, 15 patients (94%) were moderate-to-excellent responders at 48 weeks of treatment. Patients with higher SNOT-22 scores, ACQ-7 scores, the rate of asthma exacerbations in the previous year, and blood eosinophil counts benefited more from the treatment. CONCLUSION Dupilumab improved upper and lower airway outcomes especially in patients with severe CRSwNP with comorbid, poorly controlled asthma. TRIAL REGISTRATION UMIN Clinical Trials Registry: UMIN000038669.
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Affiliation(s)
- Tomoko Tajiri
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan.
| | - Motohiko Suzuki
- Department of Otorhinolaryngology & Head and Neck Surgery, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Hirono Nishiyama
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Yoshiyuki Ozawa
- Department of Diagnostic Radiology, Fujita Health University School of Medicine, Aichi, Japan
| | - Ryota Kurokawa
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Keima Ito
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Kensuke Fukumitsu
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Yuta Mori
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Yoshihiro Kanemitsu
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Satoshi Fukuda
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Takehiro Uemura
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Hirotsugu Ohkubo
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Masaya Takemura
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Ken Maeno
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Yutaka Ito
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Tetsuya Oguri
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Shinichi Iwasaki
- Department of Otorhinolaryngology & Head and Neck Surgery, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Akio Niimi
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
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Mathur V, Karvar M, Lo T, Raby BA, Tavakkoli A, Croteau-Chonka DC, Sheu EG. Sleeve Gastrectomy is Associated with Longitudinal Improvements in Lung Function and Patient-Reported Respiratory Outcomes. Obes Surg 2024; 34:2467-2474. [PMID: 38753264 DOI: 10.1007/s11695-024-07274-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 05/09/2024] [Accepted: 05/09/2024] [Indexed: 07/03/2024]
Abstract
PURPOSE Obesity exerts negative effects on pulmonary function through proven mechanical and biochemical pathways. Multiple studies have suggested that bariatric surgery can improve lung function. However, the timing of these effects on lung function and its association with patient reported outcomes is not known. MATERIALS AND METHODS A prospective cohort study of patients undergoing laparoscopic sleeve gastrectomy (LSG) at a tertiary care hospital was undertaken. Spirometry tests, laboratory tests, and self-reported questionnaires on asthma symptoms and asthma control (ACQ and ACT) were administered. All data were recorded pre-operatively (T0) and every 3 months post-operatively for 1 year (T3, T6, T9, T12) and were compared using a mixed-models approach for repeated measures. RESULTS For the 23 participants, mean age was 44.2 ± 12.3 years, mean BMI was 45.2 ± 7.2 kg/m2, 18(78%) were female, 9(39%) self-reported as non-white and 6(26%) reported to have asthma. Following LSG, % total body weight loss was significant at all follow-up points (P < 0.0001). Rapid improvement in forced expiratory volume (FEV)% predicted and forced vital capacity (FVC)% predicted was seen at T3. Although the overall ACQ and ACT score remained within normal range throughout the study, shortness of breath declined significantly at 3 months post-op (P < 0.05) and wheezing resolved for all patients by twelve months. Patients also reported reduced frequency of sleep interruption and inability to exercise by the end of the study (P < 0.05). CONCLUSION Improvements in objective lung function assessments and patient-reported respiratory outcomes begin as early as 3 months and continue until 12 months after sleeve gastrectomy.
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Affiliation(s)
- Vasundhara Mathur
- Laboratory of Surgical and Metabolic Research, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Mehran Karvar
- Laboratory of Surgical and Metabolic Research, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Tammy Lo
- Laboratory of Surgical and Metabolic Research, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Benjamin A Raby
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pulmonary Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ali Tavakkoli
- Laboratory of Surgical and Metabolic Research, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Damien C Croteau-Chonka
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Eric G Sheu
- Laboratory of Surgical and Metabolic Research, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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Barbosa RCC, Silva RA, Lunardi AC, Silva STC, Corso SD, Fonseca AJ, Stelmach R, Carvalho CRF. Reproducibility, validity, and reliability of the incremental step test for subjects with moderate to severe asthma. Pulmonology 2024; 30:344-351. [PMID: 35221263 DOI: 10.1016/j.pulmoe.2022.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE We investigated the measurement properties of the incremental step test in subjects with moderate to severe asthma. METHODS Subjects with moderate to severe persistent asthma were recruited from a tertiary university hospital specializing in treating severe asthma. All subjects performed one cardiopulmonary exercise test (CPET) and two incremental step tests (IST) in random sequences. Pulmonary gas exchange was measured during all exercise tests. The measurement properties investigated were reliability by intraclass correlation coefficient (ICC), measurement error by the standard error of measurement and minimum detectable difference, construct validity by Pearson's correlation, and interpretability by the ceiling and floor effects. RESULTS Fifty subjects (38 females, mean [SD], age 43.7 [11.6] yr, % FEV1 70 [14.3], BMI 28.5 [5.3] kg/m2) completed the study. The peak oxygen uptake (peak VO2) for the CPET was 27.6 [±6.8] ml/kg/min, for the first IST was 22.3 [±5.3] ml/kg/min and for the second IST was 23.3 [±5.3] ml/kg/min. The IST presented excellent reliability (ICC=0.93, CI95% 0.88-0.96), very good measurement error (2.5%), and construct validity for peak VO2 measurement compared to the CPET (r = 0.85; p < 0.001) to assess exercise capacity in subjects with moderate to severe asthma, with appropriate ceiling (10%) and floor (0%) effects. CONCLUSION The IST presented excellent reliability and very good measurement error and validity to assess exercise capacity in subjects with moderate to severe asthma, without ceiling or floor effects.
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Affiliation(s)
- R C C Barbosa
- Department of Physical Therapy, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - R A Silva
- Department of Physical Therapy, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - A C Lunardi
- Department of Physical Therapy, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - S T C Silva
- Department of Physical Therapy, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - S D Corso
- Graduate Program in Rehabilitation Sciences, Universidade Nove de Julho, São Paulo, Brazil
| | - A J Fonseca
- Department of Physical Therapy, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - R Stelmach
- Pulmonary Division, Heart Institute (InCor), Clinical Hospital, Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - C R F Carvalho
- Department of Physical Therapy, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil.
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14
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Tiotiu A, De Meulder B, Vaillant P, Mouton-Faivre C, Jaussaud R. Suboptimal Response to Biologics in Severe Asthma-A Marker of Humoral Immunodeficiencies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1840-1849.e3. [PMID: 38548169 DOI: 10.1016/j.jaip.2024.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Asthmatic patients with antibody deficiencies (AD) have more severe disease and higher risk of exacerbations. No data exist about the efficacy of biologics in severe asthma (SA) patients with AD. OBJECTIVE To evaluate the efficacy of biologics in SA patients with and without AD. METHODS A case-control real-life study was conducted including 68 patients divided into 2 groups: group 1 with SA-AD and group 2 with SA. RESULTS Treatment with biologics for 6 months was effective for decreasing the number of exacerbations, hospitalizations, and emergency department (ED) visits and improving the Asthma Control Questionnaire (ACQ) score; biologics also proved a systemic corticosteroid-sparing effect. Despite benefits, the number of exacerbations, hospitalizations, and ED visits, the mean ACQ score, and the cumulative dose of systemic corticosteroids remain higher in group 1 than in group 2, with lower lung function parameters. The rates of responses in group 1 were inferior to those in group 2, with a decrease by ≥50% of exacerbation rate in 76% versus 97% of patients (P = .006), no hospitalization in 44% versus 91% of patients (P < .001), no ED visit in 56% versus 82% of patients (P = .018), a significant improvement of the ACQ score by ≥0.5 in 68% versus 100% of patients (P < .001), and an increase of forced expiratory volume in the first second by >10% in 32% versus 65% of patients (P = .007). CONCLUSIONS Despite evident benefits, SA patients with AD have suboptimal responses to biologics compared with those immunocompetent. A multidisciplinary approach is necessary to optimize the management of these patients in practice.
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Affiliation(s)
- Angelica Tiotiu
- Department of Pneumology, University Hospital Saint-Luc, University of Louvain, Brussels, Belgium; Pole Pneumology, ENT and Dermatology-LUNS, Institute of Experimental and Clinical Research (IREC), UCLouvain, Brussels, Belgium.
| | | | - Pierre Vaillant
- Department of Pneumology, University Hospital of Nancy, Nancy, France
| | | | - Roland Jaussaud
- Department of Internal Medicine, University Hospital of Nancy, Nancy, France; Faculty of Medicine, University of Lorraine, Nancy, France
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15
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Walsh LJ, Sullivan A, Ward C, Hunt EB, Lapthorne S, Eustace JA, Fanning LJ, Plant BJ, O'Byrne PM, MacSharry JA, Murphy DM. Airway and Systemic Immunoglobulin Profiling and Immune Response in Adult Asthma. Lung 2024; 202:281-289. [PMID: 38713421 PMCID: PMC11142944 DOI: 10.1007/s00408-024-00699-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 04/12/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Immunoglobulins play a vital role in host immune response and in the pathogenesis of conditions like asthma. Therapeutic agents such as monoclonal antibodies target specific elements of the asthmatic inflammatory cascade. Decisions to utilize these medications are often based on systemic inflammatory profiling without direct insight into the airway inflammatory profile. We sought to investigate the relationship between immunoglobulin and cytokine profiles in the airway and systemic immune compartments of adult asthmatics. METHODS Blood sampling and bronchoscopy with bronchoalveolar lavage (BAL) were performed in 76 well-defined adult asthmatics. Antibody and cytokine profiles were measured in both BAL and serum using ELISA and quantibody arrays. RESULTS There was no relationship between BAL and serum levels of IgE. This is of significance in an asthma population. For some analytes, correlation analysis was significant (P < 0.05) indicating representativeness of our cohort and experimental setup in those cases. Nevertheless, the predictive power (r2) of the BAL-to-serum comparisons was mostly low except for TNF-α (r2 = 0.73) when assuming a simple (linear) relationship. CONCLUSION This study highlights the importance of sample site when investigating the roles of immunoglobulins and cytokines in disease pathogenesis and suggests that both localized and systemic immune responses are at play. The prescription of asthma monoclonal therapy is generally based on systemic evaluation of cytokine and immunoglobulin levels. Our research suggests that this approach may not fully reflect the pathophysiology of the disease and may provide insight into why some patients respond to these targeted therapies while others do not.
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Affiliation(s)
- Laura J Walsh
- The School of Medicine, University College Cork, Cork, Ireland
- The Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland
- The HRB funded Clinical Research Facility, University College Cork, Cork, Ireland
| | - Ashley Sullivan
- The School of Medicine, University College Cork, Cork, Ireland
- APC Microbiome Ireland, University College Cork, Cork, Ireland
- The School of Microbiology, University College Cork, Cork, Ireland
| | - Chris Ward
- Translational and Clinical Research Institute Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Eoin B Hunt
- The Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland
- The HRB funded Clinical Research Facility, University College Cork, Cork, Ireland
| | - Susan Lapthorne
- APC Microbiome Ireland, University College Cork, Cork, Ireland
| | - Joseph A Eustace
- The HRB funded Clinical Research Facility, University College Cork, Cork, Ireland
| | - Liam J Fanning
- The School of Medicine, University College Cork, Cork, Ireland
- The HRB funded Clinical Research Facility, University College Cork, Cork, Ireland
| | - Barry J Plant
- The Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland
- The HRB funded Clinical Research Facility, University College Cork, Cork, Ireland
| | - Paul M O'Byrne
- The Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - John A MacSharry
- The School of Medicine, University College Cork, Cork, Ireland
- APC Microbiome Ireland, University College Cork, Cork, Ireland
- The School of Microbiology, University College Cork, Cork, Ireland
| | - Desmond M Murphy
- The Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland.
- The HRB funded Clinical Research Facility, University College Cork, Cork, Ireland.
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Ma J, Chen Z, Wu K, Lei J, Zhao L. Risk factor analysis and nomogram for predicting poor symptom control in smoking asthmatics. BMC Pulm Med 2024; 24:264. [PMID: 38824531 PMCID: PMC11144325 DOI: 10.1186/s12890-024-03076-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 05/27/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND Smoking induces and modifies the airway immune response, accelerating the decline of asthmatics' lung function and severely affecting asthma symptoms' control level. To assess the prognosis of asthmatics who smoke and to provide reasonable recommendations for treatment, we constructed a nomogram prediction model. METHODS General and clinical data were collected from April to September 2021 from smoking asthmatics aged ≥14 years attending the People's Hospital of Zhengzhou University. Patients were followed up regularly by telephone or outpatient visits, and their medication and follow-up visits were recorded during the 6-months follow-up visit, as well as their asthma control levels after 6 months (asthma control questionnaire-5, ACQ-5). The study employed R4.2.2 software to conduct univariate and multivariate logistic regression analyses to identify independent risk factors for 'poorly controlled asthma' (ACQ>0.75) as the outcome variable. Subsequently, a nomogram prediction model was constructed. Internal validation was used to test the reproducibility of the model. The model efficacy was evaluated using the consistency index (C-index), receiver operating characteristic (ROC) curve, calibration curve, and decision curve. RESULTS Invitations were sent to 231 asthmatics who smoked. A total of 202 participants responded, resulting in a final total of 190 participants included in the model development. The nomogram established five independent risk factors (P<0.05): FEV1%pred, smoking index (100), comorbidities situations, medication regimen, and good or poor medication adherence. The area under curve (AUC) of the modeling set was 0.824(95%CI 0.765-0.884), suggesting that the nomogram has a high ability to distinguish poor asthma control in smoking asthmatics after 6 months. The calibration curve showed a C-index of 0.824 for the modeling set and a C-index of 0.792 for the self-validation set formed by 1000 bootstrap sampling, which means that the prediction probability of the model was consistent with reality. Decision curve analysis (DCA) of the nomogram revealed that the net benefit was higher when the risk threshold probability for poor asthma control was 4.5 - 93.9%. CONCLUSIONS FEV1%pred, smoking index (100), comorbidities situations, medication regimen, and medication adherence were identified as independent risk factors for poor asthma control after 6 months in smoking asthmatics. The nomogram established based on these findings can effectively predict relevant risk and provide clinicians with a reference to identify the poorly controlled population with smoking asthma as early as possible, and to select a better therapeutic regimen. Meanwhile, it can effectively improve the medication adherence and the degree of attention to complications in smoking asthma patients.
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Affiliation(s)
- Jinxin Ma
- Department of Respiratory and Critical Care Medicine, People's Hospital of Zhengzhou University, Zhengzhou, Henan Province, 450003, People's Republic of China
- Department of Respiratory and Critical Care Medicine, Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang, Henan Province, 471009, People's Republic of China
| | - Ziheng Chen
- Department of Respiratory and Critical Care Medicine, People's Hospital of Zhengzhou University, Zhengzhou, Henan Province, 450003, People's Republic of China
| | - Ke Wu
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou Province, 550004, People's Republic of China
| | - Jiahui Lei
- Department of Respiratory and Critical Care Medicine, People's Hospital of Zhengzhou University, Zhengzhou, Henan Province, 450003, People's Republic of China
| | - Limin Zhao
- Department of Respiratory and Critical Care Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou, Henan Province, 450003, People's Republic of China.
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Godbout K, Kim H, Mayers I, Paterson J, Chan CKN. A survey of severe asthma in Canada: results from the CASCADE practice reflective program. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2024; 20:31. [PMID: 38637825 PMCID: PMC11027544 DOI: 10.1186/s13223-024-00891-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/02/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Since the last guidance was published by the Canadian Thoracic Society, there have been several advances in the clinical management of severe asthma. To gain a better understanding of the current standards of care and treatment patterns of patients, the CASCADE practice reflective program was established to conduct a real-world analysis of severe asthma management among specialists in Canada with a goal of identifying areas of opportunity to enhance patient management and outcomes. METHODS The CASCADE program was a two-part practice reflective and assessment program delivered through an on-line portal for selected specialists (Respirologists and Allergists) in Canada. The program consisted of a one-time overview survey of physician practice to establish overall practice parameters, followed by a review of at least 5 severe asthma patients to establish the current landscape of severe asthma management. RESULTS The program collected practice overview surveys from 78 specialists (52 Respirologists, 24 Allergists, and 2 General practice physicians with an interest in respiratory disease) in 8 provinces. Practices included a variety of types in both large metropolitan centres and smaller regional settings. There were 503 patients reviewed and included in the program. Most (65%) patients were currently using a biologic treatment, 30% were biologic naive, and 5% had used a biologic treatment in the past. Most patients (53%) were reported to have mixed allergic and eosinophilic phenotypes, despite a perception that allergic, eosinophilic and mixed phenotypes were evenly balanced in the physician practice. Overall, patients currently treated with biologic agents had parameters suggesting higher control and were more satisfied with treatment. However, there was less than optimal treatment satisfaction for more than half of all patients, particularly for those patients not treated with a biologic agent. CONCLUSIONS Phenotyping is hampered by poor availability for several assessments, and the full range of treatments are not currently fully utilized, partly due to physician familiarity with the agents and partly due to prescribing restrictions. Even when treated with biologic agents, patient satisfaction can still be improved.
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Affiliation(s)
- Krystelle Godbout
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Harold Kim
- Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Irvin Mayers
- Division of Pulmonary Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - James Paterson
- Scientific Insights Consulting Group Inc., Mississauga, ON, Canada
| | - Charles K N Chan
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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Loewenthal L, Busby J, McDowell R, Brown T, Burhan H, Chaudhuri R, Dennison P, Dodd JW, Doe S, Faruqi S, Gore R, Idris E, Jackson DJ, Patel M, Pantin T, Pavord I, Pfeffer PE, Price DB, Rupani H, Siddiqui S, Heaney LG, Menzies-Gow A. Impact of sex on severe asthma: a cross-sectional retrospective analysis of UK primary and specialist care. Thorax 2024; 79:403-411. [PMID: 38124220 DOI: 10.1136/thorax-2023-220512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION After puberty, females are more likely to develop asthma and in a more severe form than males. The associations between asthma and sex are complex with multiple intrinsic and external factors. AIM To evaluate the sex differences in the characteristics and treatment of patients with severe asthma (SA) in a real-world setting. METHODS Demographic, clinical and treatment characteristics for patients with SA in the UK Severe Asthma Registry (UKSAR) and Optimum Patient Care Research Database (OPCRD) were retrospectively analysed by sex using univariable and multivariable logistic regression analyses adjusted for year, age and hospital/practice. RESULTS 3679 (60.9% female) patients from UKSAR and 18 369 patients (67.9% female) from OPCRD with SA were included. Females were more likely to be symptomatic with increased Asthma Control Questionnaire-6 (UKSAR adjusted OR (aOR) 1.14, 95% CI 1.09 to 1.18) and Royal College of Physicians-3 Question scores (OPCRD aOR 1.29, 95% CI 1.13 to 1.47). However, they had a higher forced expiratory volume in 1 second per cent (FEV1%) predicted (UKSAR 68.7% vs 64.8%, p<0.001) with no significant difference in peak expiratory flow. Type 2 biomarkers IgE (UKSAR 129 IU/mL vs 208 IU/mL, p<0.001) and FeNO (UKSAR 36ppb vs 46ppb, p<0.001) were lower in females with no significant difference in blood eosinophils or biological therapy. Females were less likely to be on maintenance oral corticosteroids (UKSAR aOR 0.86, 95% CI 0.75 to 0.99) but more likely to be obese (UKSAR aOR 1.67, 95% CI 145 to 1.93; OPCRD SA aOR 1.46, 95% CI 1.34 to 1.58). CONCLUSIONS Females had increased symptoms and were more likely to be obese despite higher FEV1% predicted and lower type 2 biomarkers with consistent and clinically important differences across both datasets.
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Affiliation(s)
- Lola Loewenthal
- National Lung and Heart Institute, Imperial College London, London, UK
- Department of Asthma and Allergy, Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, London, UK
| | - John Busby
- Centre for Public Health, Queen's University Belfast School of Medicine Dentistry and Biomedical Sciences, Belfast, UK
| | - Ronald McDowell
- Queen's University Belfast, Belfast, UK
- Ulster University, Coleraine, UK
| | - Thomas Brown
- Respiratory Medicine, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Hassan Burhan
- Respiratory Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Rekha Chaudhuri
- Respiratory Medicine, Gartnavel General Hospital, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Paddy Dennison
- Southampton NIHR Respiratory Biomedical Research Unit, Southampton University Hospitals NHS Trust, Southampton, UK
| | - James William Dodd
- Academic Respiratory Unit, University of Bristol, Bristol, UK
- North Bristol Lung Centre, North Bristol NHS Trust, Westbury on Trym, UK
| | - Simon Doe
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Shoaib Faruqi
- Hull University Teaching Hospitals NHS Trust, Hull, UK
| | | | | | - David Joshua Jackson
- Guy's Severe Asthma Centre, Guy's and St Thomas' Hospitals NHS Trust, London, UK
- Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Mitesh Patel
- University Hospitals Plymouth, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Thomas Pantin
- Respiratory Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Ian Pavord
- NIHR Respiratory BRC, Nuffield Department of Medicine, Oxford University, Oxford, UK
| | | | - David B Price
- Observational and Pragmatic Research Institute Pte Ltd, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Hitasha Rupani
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- University of Southampton, Southampton, UK
| | - Salman Siddiqui
- National Lung and Heart Institute, Imperial College London, London, UK
| | - Liam G Heaney
- Centre of Infection and Immunity, Queen's University Belfast, Belfast, UK
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19
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Fitzpatrick AM, Kavalieratos D, Vickery BP, Lee T, Mason C, Grunwell JR. Altered Symptom Perception in Children With Asthma Is Associated With Poor Childhood Opportunity and Adverse Outcomes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:983-990. [PMID: 38142865 PMCID: PMC10999352 DOI: 10.1016/j.jaip.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 12/12/2023] [Accepted: 12/12/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND Effective asthma self-management requires that children recognize their asthma symptoms when they occur. However, some children have altered symptom perception, which impairs their ability to respond to their asthma symptoms in a timely manner. OBJECTIVE To characterize the prevalence and features of altered symptom perception in children aged 5 to 18 years. We hypothesized that children with altered symptom perception would have more features of uncontrolled asthma, more health inequity, and poorer longitudinal asthma outcomes over 12 months. METHODS Children (N = 371) completed an outpatient research visit for clinical characterization. Altered symptom perception was defined by discordance between child responses on the 6-item Asthma Control Questionnaire and medical provider-elicited symptoms. Electronic medical records were reviewed for 12 months for the occurrence of an asthma exacerbation treated with systemic corticosteroids and an asthma exacerbation prompting an emergency department visit. RESULTS Approximately 15% of children had altered symptom perception and their asthma features were similar to those of children with uncontrolled asthma. Children with altered symptom perception were uniquely distinguished by non-White race and more severe prior exacerbations. These children also resided in ZIP codes with the poorest childhood opportunity (ie, poorest education, health and environmental features, and socioeconomic features). Outcomes of children with altered symptom perception were equally disparate with approximately 2-fold higher odds of a future exacerbation and approximately 3-fold higher odds of an emergency department visit for asthma. CONCLUSIONS Altered symptom perception is present in a small but significant number of children with asthma and is related to poorer childhood opportunity and other health inequities that require additional intervention.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Dio Kavalieratos
- Department of Pediatrics, Emory University, Atlanta, Ga; Department of Family and Preventative Medicine, Emory University, Atlanta, Ga
| | - Brian P Vickery
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga
| | - Tricia Lee
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga
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20
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da Silva RA, Cukier A, Carvalho-Pinto RM, Carvalho CR. Effects of constant-load exercise and high-intensity interval training on reliever medication consumption and peak expiratory flow in individuals with asthma: a randomised controlled trial. ERJ Open Res 2024; 10:00899-2023. [PMID: 38469374 PMCID: PMC10926009 DOI: 10.1183/23120541.00899-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/14/2024] [Indexed: 03/13/2024] Open
Abstract
Introduction The effect of aerobic training on reliever medication consumption (short-acting β2-agonist (SABA)) and peak expiratory flow (PEF) in participants with asthma is poorly known. The comparison between constant-load exercise (CLE) and high-intensity interval training (HIIT) in these outcomes has never been tested. The purpose of the present study was to compare the effects of CLE or HIIT in SABA consumption and PEF improvement during an exercise programme in subjects with asthma. Methods Clinically stable participants were randomised into CLE (n=27; 70-85% of the maximal load (Wmax)) or HIIT (n=28; 80-140% Wmax). The programme lasted 12 weeks (two sessions per week, 40 min per session), and the intensity was based on cardiopulmonary exercise testing (CPET). PEF was assessed before and after each exercise session. SABA was used if PEF was <70%. Clinical control (Asthma Control Questionnaire (ACQ)-6), CPET and aerobic fitness were also assessed before and after the intervention. Results Both groups were similar at baseline. CLE and HIIT reduced SABA consumption throughout the intervention (p<0.05). Before training, 14 patients required SABA before exercising, but only one needed it after the intervention. Changes in post-exercise PEF were lower in the CLE group than in the HIIT group (1.6±25.3 versus 10.3±13.7%). Both groups improved aerobic fitness (10.1±12.8% versus 5.7±15.6%) and clinical asthma control; however, only the HIIT group achieved a minimal clinically important difference in the ACQ-6 post-intervention (-0.23±1.06 versus -0.52±0.73 Δ score). Conclusion CLE and HIIT reduced SABA consumption; however, only HIIT increased PEF and asthma clinical control after the intervention. These results reinforce the importance of exercise training in moderate-to-severe asthma.
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Affiliation(s)
| | - Alberto Cukier
- Pulmonary Division, Heart Institute (InCor), Clinics Hospital, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Regina Maria Carvalho-Pinto
- Pulmonary Division, Heart Institute (InCor), Clinics Hospital, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Celso R.F. Carvalho
- Department of Physical Therapy, School of Medicine, University of São Paulo, São Paulo, Brazil
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21
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Agarwal CD, Palka JM, Gajewski AJ, Khan DA, Brown ES. The efficacy of citalopram or escitalopram in patients with asthma and major depressive disorder. Ann Allergy Asthma Immunol 2024; 132:374-382. [PMID: 37952772 DOI: 10.1016/j.anai.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Major depressive disorder is common in people with asthma. Yet, few studies have evaluated depression treatment in those with asthma. OBJECTIVE To explore the relationship between antidepressant use, depressive symptoms, and asthma control, pooled data from 3 randomized trials of either citalopram or escitalopram were assessed. METHODS Linear fixed effects and binary logistic regression analyses were conducted with between-subject covariates including treatment group, (original) study, and demographics. The within-subject effect of visit, and a treatment group-visit (between-within) interaction effect, were also evaluated. Analyses were repeated in a high asthma exacerbation subgroup having at least 3 oral corticosteroid bursts in the previous 12 months. Outcomes included the Hamilton rating scale for depression (HAM-D17), the 7-item asthma control questionnaire (ACQ), and oral corticosteroid use (yes or no). RESULTS In the pooled sample (n = 255), the antidepressant treatment group exhibited lower HAM-D17 overall (P ≤ .001) and a lower likelihood for oral corticosteroid use (P ≤ .001) relative to the placebo group. In the high-exacerbation subgroup (n = 96), treatment group participants had lower overall asthma control questionnaire (P = .004) and HAM-D17 scores (P ≤ .001), and a lower likelihood of oral corticosteroid use (P = .003), relative to placebo participants. All treatment group interaction effects were not significant. CONCLUSION Citalopram or escitalopram exhibited efficacy in reducing depressive symptoms and the need for rescue oral corticosteroids in patients with asthma and major depressive disorder. Future work should determine whether selective serotonin reuptake inhibitors are effective at improving asthma outcomes in those with asthma who are not depressed. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT00621946 and NCT01324700 (one study was conducted before ClinicalTrials.gov requirements).
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Affiliation(s)
- Catherine D Agarwal
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jayme M Palka
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alexander J Gajewski
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - E Sherwood Brown
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, Texas; The Altshuler Center for Education and Research, Metrocare Services, Dallas, Texas.
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22
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Rockette-Wagner B, Wisnivesky JP, Holguin F, Ankam J, Arora A, Federmann E, Smith V, Federman AD, Conroy MB. The relationships between Physical activity and asthma control and Body Mass Index (BMI) in patients with asthma. J Asthma 2024; 61:194-202. [PMID: 37847059 DOI: 10.1080/02770903.2023.2260868] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/05/2023] [Accepted: 09/14/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVE Asthma is one of the most common chronic conditions in developed countries. We examined whether physical activity (PA) is related to asthma control and body mass index (BMI) in asthma patients. METHODS Cross-sectional data collected on PA (ActiGraph GT3X-BT), asthma control (the Asthma Control Questionnaire; ACQ), and BMI were examined in 206 adults (mean[sd] age 47.2[13.8] years; 49.5% had an obese BMI) with clinically diagnosed asthma. Relationships between PA and continuous BMI and asthma control were assessed using linear regression. Differences in PA across obesity (non-obese: <30 Kg/m2/obese: ≥30 Kg/m2) and asthma control categories (controlled: ≤0.75/uncontrolled: >0.75 ACQ score) were also examined. RESULTS Median (p25, p75) steps counts and peak cadence were 6035 (4248, 8461) steps/day and 123 (115, 133) steps in a minute, respectively. There were nearly 2000 fewer steps/day among those with uncontrolled asthma versus controlled and among those with obese BMI versus nonobese, respectively (both p < 0.05). In regression models adjusted for relevant covariates each 1-unit increase in ACQ score was associated with -686 [95%CI -997, -13] (p ≤ 0.05) average steps/day. The statistical significance of these findings was attenuated (p ≥ 0.05) when BMI was added to the model. However, the point estimate was not reduced (-766 [95%CI -1060, 34]. CONCLUSIONS Overall step counts were low in this population despite peak cadence values suggesting that most participants could perform moderate intensity activity. Increasing step counts should be considered an important lifestyle intervention goal in obese and non-obese asthma patients with low PA levels.
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Affiliation(s)
| | - Juan P Wisnivesky
- Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
| | - Fernando Holguin
- Anschutz School of Medicine, University of Colorado, Denver, CO, USA
| | - Jyoti Ankam
- Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
| | - Arushi Arora
- Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
| | - Emily Federmann
- Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
| | - Vongphone Smith
- Anschutz School of Medicine, University of Colorado, Denver, CO, USA
| | - Alex D Federman
- Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
| | - Molly B Conroy
- School of Medicine, University of Utah, Salt Lake City, UT, USA
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23
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Chan R, Lipworth B. Identifying poorer asthma control using oscillometry ratios. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:506-508.e1. [PMID: 37923128 DOI: 10.1016/j.jaip.2023.10.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/01/2023] [Accepted: 10/28/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Rory Chan
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, United Kingdom.
| | - Brian Lipworth
- Scottish Centre for Respiratory Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, United Kingdom
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24
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Morris T, Wood R, Silvey M, Diomatari C, Lipworth J, Menon S. Characteristics and outcomes of patients enrolled in the Connect 360 benralizumab patient support programme in the UK: a retrospective cohort study. BMJ Open Respir Res 2024; 11:e001734. [PMID: 38262668 PMCID: PMC10824014 DOI: 10.1136/bmjresp-2023-001734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 01/04/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Patient support programmes (PSPs) allow patients with chronic diseases to receive treatment and support at home. This study describes the Connect 360 PSP delivery and impact on patient-reported outcomes, satisfaction and adherence/persistence among benralizumab-treated patients with severe eosinophilic asthma (SEA). METHODS A non-interventional retrospective cohort study using data collected during routine care in the Connect 360 PSP. All consenting enrollees (≥18 years) were included in the study. RESULTS 746 patients formed the study cohort. Mean (SD) age was 53.7 (14.5) years on PSP entry; 38.3% were female (38.7% unknown). 79.6% of patients were experienced biological therapy users. Oral corticosteroid (OCS) use was reported in 48.4% of patients at baseline and 34.8% at 48 weeks. 8.2% of patients reported asthma hospitalisation in the previous 6 months at 24 weeks vs 3.0% at 48 weeks. Mean (SD) 6-item Asthma Control Questionnaire (ACQ-6) scores were 2.7 (1.5) at baseline vs 1.6 (1.3) at 48 weeks. Mean (SD) patient satisfaction scores remained high (4.5 of 5 (1.0) at baseline; 4.7 of 5 (0.6) at 48 weeks). 28.3% of patients were considered adherent at 24 weeks, increasing to 98.3% when supplemented with sales/delivery data (sensitivity analysis). Discontinuation from PSP/benralizumab was low at 24 (3.4%/3.0%) and 48 (12.6%/5.8%) weeks. CONCLUSIONS Connect 360 PSP achieved high levels of satisfaction and persistence, with indications of positive outcomes including OCS use, hospitalisation and ACQ-6. The study was conducted during COVID-19, so it provides reassurance that patients with SEA receiving benralizumab may be supported safely and effectively at home.
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Affiliation(s)
- Tamsin Morris
- Medical & Scientific Affairs, AstraZeneca UK, London, UK
| | | | | | | | - Joe Lipworth
- Medical & Scientific Affairs, AstraZeneca UK, London, UK
| | - Shruti Menon
- Medical & Scientific Affairs, AstraZeneca UK, London, UK
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25
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Plavsic A, Bonaci-Nikolic B, Milenkovic B, Miskovic R, Kusic N, Dimitrijevic M, Arandjelovic S, Milosevic K, Buha I, Tomic Spiric V. Asthma Inflammatory Phenotypes: How Can We Distinguish Them? J Clin Med 2024; 13:526. [PMID: 38256660 PMCID: PMC10816410 DOI: 10.3390/jcm13020526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/07/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND AND OBJECTIVES induced sputum is used to assess different inflammatory phenotypes in asthma, but is not used routinely. We aimed to determine the proportion of inflammatory asthma phenotypes based on induced sputum, to find biomarkers that can discriminate between phenotypes, and to evaluate biomarkers in patients with and without biological therapy in different inflammatory asthma phenotypes. MATERIALS AND METHODS this cross-sectional study investigated clinical characteristics, asthma control tests, skin prick test, impulse oscillometry (IOS), spirometry, induced sputum, biomarkers (IgE, eosinophils, fractional exhaled nitric oxide (FeNO), serum periostin, IL-5, IL-6, IL-8, IL-17A, IL-33) in 80 asthmatics. A total of 17/80 patients were treated with biologics (10 with omalizumab, 7 with benralizumab). RESULTS a total of 31% of patients had eosinophilic asthma (EA), 30% had mixed granulocytic asthma (MGA), 24% had paucigranulocytic asthma (PGA), and 15% had neutrophilic asthma (NA). The difference was found in blood eosinophils (p = 0.002), the highest observed in EA. The cut-off ≥ 240/μL eosinophils, with 64% sensitivity and 72.7% specificity, identified EA (AUC = 0.743, p = 0.001). A higher IL-8 level was associated with NA (p = 0.025). In 63 non-biologic asthma group, eosinophils were higher in EA than in NA, MGA, and PGA (p = 0.012, p = 0.028, and p = 0.049, respectively). A higher IL-17A was associated with EA without biologics (p = 0.004). A significantly higher IL-5 was found in EA treated with biologics, in comparison with EA without biologics (p = 0.043). The number of leucocytes and neutrophils was higher in MGA without biologics (p = 0.049, p = 0.019), while IL-5, IL-6, and IL-8 levels were higher in MGA treated with biologics (p = 0.012, p = 0.032, p = 0.038, respectively). CONCLUSIONS EA and MGA were the most prevalent asthma phenotypes. Blood eosinophils can identify EA, both in patients with and without biologics. Apart from the clinical profile, a broad spectrum of biomarkers for assessing inflammatory phenotypes is necessary for an adequate therapy approach to patients with asthma.
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Affiliation(s)
- Aleksandra Plavsic
- Clinic for Allergy and Immunology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (B.B.N.); (R.M.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (B.M.)
| | - Branka Bonaci-Nikolic
- Clinic for Allergy and Immunology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (B.B.N.); (R.M.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (B.M.)
| | - Branislava Milenkovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (B.M.)
- Clinic for Pulmonology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Rada Miskovic
- Clinic for Allergy and Immunology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (B.B.N.); (R.M.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (B.M.)
| | - Natasa Kusic
- Clinic for Allergy and Immunology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (B.B.N.); (R.M.)
| | - Milan Dimitrijevic
- Clinic for Allergy and Immunology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (B.B.N.); (R.M.)
| | - Snezana Arandjelovic
- Clinic for Allergy and Immunology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (B.B.N.); (R.M.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (B.M.)
| | - Katarina Milosevic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (B.M.)
- Department of Pulmonology and Allergology, University Children’s Hospital, 11000 Belgrade, Serbia
| | - Ivana Buha
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (B.M.)
- Clinic for Pulmonology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Vesna Tomic Spiric
- Clinic for Allergy and Immunology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (B.B.N.); (R.M.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (B.M.)
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Rebrova S, Emelyanov A, Sergeeva G, Korneenkov A. Markers of eosinophilic airway inflammation in patients with asthma and allergic rhinitis. Allergy Asthma Proc 2024; 45:e9-e13. [PMID: 38151732 DOI: 10.2500/aap.2024.45.230077] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Background: Measurement of airway inflammation is an important step to determine phenotype of asthma and allergic rhinitis (AR). Objective: To assess the level of nitric oxide in exhaled air (FeNO), nasal fraction of nitric oxide (nasal NO), their relationship with clinical control and blood eosinophils in patients with steroid-naive mild and moderate asthma and AR. Methods: One hundred forty-seven patients (65 men), ages 26-49.5 years (mean age, 32 years) with AR (n = 81) or AR and concomitant asthma (n = 46) and 20 healthy subjects were included in a single-center cohort study. All the patients underwent spirometry with reversibility test. Control of asthma and AR was assessed by using the Asthma Control Questionnaire and the visual analog scale, respectively. Levels of FeNO and nasal NO were measured by chemiluminescent analyzer, peripheral blood eosinophils were counted by automatic analyzer. Results: The FeNO level was significantly elevated in the patients with asthma and concomitant AR compared with the healthy subjects and was associated with control of both asthma and AR. There was no correlation between nasal NO and control of AR. Receiver operating characteristic analysis revealed that the level of eosinophils of 150 cells/μL may be a cutoff for lower airway eosinophilic inflammation. Blood eosinophils count was unable to distinguish eosinophilic and non-eosinophilic upper airway inflammation. Conclusion: We confirm that FeNO but not nasal NO is a marker of eosinophilic airway inflammation in patients with mild-moderate steroid-naive AR and concomitant asthma. A blood eosinophil level of ≥150 cells/µL may be a simple marker of eosinophilic airway inflammation in patients with asthma. However, its low specificity requires repeated measurements and use in combination with other biomarkers.
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Affiliation(s)
- Svetlana Rebrova
- From the Saint-Petersburg Scientific Research Institute of Ear, Throat, Nose and Speech, Saint-Petersburg, Russia, and
| | - Alexander Emelyanov
- Department of Respiratory Medicine, North-Western Medical University named I.I. Mechnikov, Saint-Petersburg, Russia
| | - Galina Sergeeva
- Department of Respiratory Medicine, North-Western Medical University named I.I. Mechnikov, Saint-Petersburg, Russia
| | - Alexey Korneenkov
- From the Saint-Petersburg Scientific Research Institute of Ear, Throat, Nose and Speech, Saint-Petersburg, Russia, and
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Michils A, Akset M, Haccuria A, Perez-Bogerd S, Malinovschi A, Van Muylem A. The Impact of Airway Obstruction on Feno Values in Asthma Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:111-117. [PMID: 37634805 DOI: 10.1016/j.jaip.2023.08.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 07/20/2023] [Accepted: 08/16/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Exhaled nitric oxide (Feno) is used as a marker of type-2 airway inflammation in asthma management. Studies with airway challenges demonstrated that a reduction in airway caliber decreases Feno levels. OBJECTIVE To evaluate the impact of airway caliber reduction occurring spontaneously in patients with asthma on Feno values in daily clinical practice. METHODS In this post hoc analysis, Feno, FEV1, and asthma control questionnaire scores were recorded on each visit for 120 (1073 visits) adult patients with asthma. Blood eosinophils were measured intermittently. The intraindividual relationship between Feno and FEV1 was evaluated via a linear mixed model. The determinants of the individual mean Feno were measured by a stepwise multivariate linear model including individual mean FEV1, inhaled corticosteroid dose, asthma control questionnaire score, and blood eosinophils. RESULTS Variations in the negative Feno-FEV1 relationship within individuals at different times were significantly determined by the individual's mean FEV1. This relationship did not hold for individuals above the 75th and below the 25th quartiles. The best explanatory variables for individual mean Feno were FEV1 (+4.3 parts per billion/10%pred) and blood eosinophil count (+1 part per billion per 100 cells/mm3). DISCUSSION In the presence of variable degrees of heterogeneous patterns of airway inflammation, airway caliber is shown to be an independent and significant determinant of Feno when measured in patients with asthma. We would propose a +4-parts-per-billion correction factor to the measured Feno value for each 10% reduction below 100% predicted FEV1. Doing this should improve the rigor of interpretation of Feno as an indicator of type-2 inflammation in patients with low FEV1.
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Affiliation(s)
- Alain Michils
- Chest Department, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Maud Akset
- Chest Department, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Amaryllis Haccuria
- Chest Department, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Silvia Perez-Bogerd
- Chest Department, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Andreï Malinovschi
- Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Alain Van Muylem
- Chest Department, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium.
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Chen X, Luo H, Yan W, Tang K, Huang J, Xie S, Lin Z, Zhang Z, Shi X, Xian M, Wang W, Li J, Chen R. Real-world effectiveness and predictors of super-responders to dupilumab in a Chinese uncontrolled asthma cohort. Allergy Asthma Proc 2024; 45:e14-e22. [PMID: 38151737 DOI: 10.2500/aap.2024.45.230072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Background: Dupilumab has been shown to be effective in clinical trials for moderate-to-severe uncontrolled asthma. However, the efficacy of dupilumab in the real world and the prediction of treatment response have not been well studied in patients with asthma. Objective: To investigate the efficacy of dupilumab and explore predictors of super-responders in a Chinese retrospective cohort. Methods: From January 2021 through December 2022, the patients with uncontrolled asthma who were treated with dupilumab for 4 months were included. Symptom control, type 2 inflammatory biomarkers, and lung function were collected at baseline and follow-up for efficacy assessment. Super-responders were defined as exacerbation-free, off maintenance of oral corticosteroids (mOCS), and with a score of the five-item Asthma Control Questionnaire (ACQ-5) of <0.5. The uni- and multivariable logistic regressions were used to construct predictive models for super-responders based on baseline features. Results: A total of 53 patients were included. After 4 months treatment, the median (interquartile range [IQR]) ACQ-5 score decreased from 1.8 (1.6-2.4) to 0.4 (0.2-0.8) (p < 0.001), the median (IQR) number of exacerbations, from 0.0 (0.0-1.0) to 0.0 (0.0-0.0) (p = 0.005). The median (IQR) dose of mOCS (prednisone equivalent) decreased from 15.0 mg/day (8.8-22.5 mg/day) to 2.5 mg/day (0.0-10.0 mg/day) (p = 0.008) in nine patients who were receiving mOCS. All efficacy assessment parameters, including sputum eosinophil were significantly improved, while blood eosinophil count did not decline (530 cells/mm³ [300-815 cells/mm³] versus 560 cells/mm³ [220-938 cells/mm³], p = 0.710). After taking dupilumab, 25 of 53 patients (47.2%) achieved a super-response. The age of onset < 42 years (odds ratio [OR] 7.471 [95% confidence interval {CI}, 1.286-43.394) and the baseline fractional exhaled nitric oxide (FeNO) of 25-50 ppb (OR 35.038 [95% CI, 3.104-395.553]) predicted super-responders, which showed a C-index of 0.822 (95% CI, 0.697-0.947). Conclusion: Dupilumab significantly improved symptom control, type 2 inflammatory markers, and lung function in Chinese patients with uncontrolled asthma. Airway eosinophils, rather than blood eosinophils, can be a reliable indicator of therapeutic efficacy. The early-onset asthma as well as the medium-high level of baseline FeNO contributed to the prediction of super-responders.
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Affiliation(s)
- Xiaoying Chen
- From the State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health; Department of Allergy and Clinical Immunology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Huiting Luo
- From the State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health; Department of Allergy and Clinical Immunology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Wenbo Yan
- From the State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health; Department of Allergy and Clinical Immunology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Kailun Tang
- From the State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health; Department of Allergy and Clinical Immunology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Junfeng Huang
- From the State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health; Department of Allergy and Clinical Immunology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Shuojia Xie
- College of Clinical Medicine, Guangzhou Medical University, Guangzhou, Guangdong, China, and
| | - Zhenxuan Lin
- From the State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health; Department of Allergy and Clinical Immunology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zhenle Zhang
- College of Clinical Medicine, Guangzhou Medical University, Guangzhou, Guangdong, China, and
| | - Xu Shi
- From the State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health; Department of Allergy and Clinical Immunology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Mo Xian
- From the State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health; Department of Allergy and Clinical Immunology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Wanjun Wang
- From the State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health; Department of Allergy and Clinical Immunology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jing Li
- From the State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health; Department of Allergy and Clinical Immunology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Ruchong Chen
- From the State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health; Department of Allergy and Clinical Immunology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
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Joshi E, Gibson PG, McDonald VM, Murphy VE. Treatable traits in asthma during pregnancy: a call for a shift towards a precision-based management approach. Eur Respir Rev 2023; 32:230105. [PMID: 38123232 PMCID: PMC10731471 DOI: 10.1183/16000617.0105-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/16/2023] [Indexed: 12/23/2023] Open
Abstract
Asthma is the most common chronic medical condition in pregnancy. Asthma exacerbations in pregnancy are unpredictable, and are associated with adverse maternal and fetal perinatal outcomes such as preterm birth and low birthweight. Goals of asthma management in pregnancy are to establish effective asthma control and prevent exacerbations. Optimising the management of asthma in pregnancy is an important goal of practice and future research.Treatable traits is a precision medicine paradigm proposed for the management of airways diseases, which holistically addresses the complexity and heterogeneity of airways disease. It is an individualised treatment approach that aims to improve outcomes. This makes treatable traits well suited for pregnant women with asthma, who have a high prevalence of obesity, mental health conditions, poor symptom perception and suboptimal asthma management skills including low treatment adherence. These traits are measurable and treatable. In this review, we explore current knowledge on the burden of asthma, maternal and perinatal consequences of asthma during pregnancy, the treatable traits paradigm, the prevalence of treatable traits in pregnant women with asthma, and consider how the treatable traits paradigm can be integrated into the management of asthma in pregnancy.
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Affiliation(s)
- Esha Joshi
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
- Asthma and Breathing Program, Hunter Medical Research Institute, Newcastle, Australia
| | - Peter G Gibson
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
- Asthma and Breathing Program, Hunter Medical Research Institute, Newcastle, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | - Vanessa M McDonald
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
- Asthma and Breathing Program, Hunter Medical Research Institute, Newcastle, Australia
- School of Nursing and Midwifery, University of Newcastle, Newcastle, Australia
| | - Vanessa E Murphy
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
- Asthma and Breathing Program, Hunter Medical Research Institute, Newcastle, Australia
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30
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Brotto AR, Phillips DB, Rowland SD, Moore LE, Wong E, Stickland MK. Reduced tidal volume-inflection point and elevated operating lung volumes during exercise in females with well-controlled asthma. BMJ Open Respir Res 2023; 10:e001791. [PMID: 38135461 DOI: 10.1136/bmjresp-2023-001791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023] Open
Abstract
INTRODUCTION Individuals with asthma breathe at higher operating lung volumes during exercise compared with healthy individuals, which contributes to increased exertional dyspnoea. In health, females are more likely to develop exertional dyspnoea than males at a given workload or ventilation, and therefore, it is possible that females with asthma may develop disproportional dyspnoea on exertion. The purpose of this study was to compare operating lung volume and dyspnoea responses during exercise in females with and without asthma. METHODS Sixteen female controls and 16 females with asthma were recruited for the study along with 16 male controls and 16 males with asthma as a comparison group. Asthma was confirmed using American Thoracic Society criteria. Participants completed a cycle ergometry cardiopulmonary exercise test to volitional exhaustion. Inspiratory capacity manoeuvres were performed to estimate inspiratory reserve volume (IRV) and dyspnoea was evaluated using the Modified Borg Scale. RESULTS Females with asthma exhibited elevated dyspnoea during submaximal exercise compared with female controls (p<0.05). Females with asthma obtained a similar IRV and dyspnoea at peak exercise compared with healthy females despite lower ventilatory demand, suggesting mechanical constraint to tidal volume (VT) expansion. VT-inflection point was observed at significantly lower ventilation and V̇O2 in females with asthma compared with female controls. Forced expired volume in 1 s was significantly associated with VT-inflection point in females with asthma (R2=0.401; p<0.01) but not female controls (R2=0.002; p=0.88). CONCLUSION These results suggest that females with asthma are more prone to experience exertional dyspnoea, secondary to dynamic mechanical constraints during submaximal exercise when compared with females without asthma.
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Affiliation(s)
- Andrew R Brotto
- Pulmonary Division, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Devin B Phillips
- Pulmonary Division, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada
| | - Samira D Rowland
- Pulmonary Division, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Linn E Moore
- Pulmonary Division, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Eric Wong
- Pulmonary Division, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Michael K Stickland
- Pulmonary Division, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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31
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McDowell R, Heaney L, Brown T, Bunting B, Burhan H, Chaudhuri R, Dennison P, Faruqi S, Gore R, Jackson DJ, Menzies-Gow A, Pantin T, Patel M, Pfeffer P, Siddiqui S, Busby J. An examination of factorial invariance of the Asthma Control Questionnaire among adults with severe asthma. PLoS One 2023; 18:e0295493. [PMID: 38060586 PMCID: PMC10703262 DOI: 10.1371/journal.pone.0295493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 11/22/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND The Asthma Control Questionnaire (ACQ) is used to assess asthma symptom control. The relationship between the questionnaire items and symptom control has not been fully studied in severe asthmatic patients, and its validity for making comparisons between subgroups of patients is unknown. METHODS Data was obtained from patients in the United Kingdom Severe Asthma Registry whose symptom control was assessed using the five-item ACQ (ACQ5) (n = 2,951). Confirmatory factor analysis determined whether a latent factor for asthma symptom control, as measured by the ACQ5, was consistent with the data. Measurement invariance was examined in relation to ethnicity, sex and age; this included testing for approximate measurement invariance using Bayesian Structural Equation Modelling (BSEM). The fitted models were used to estimate the internal consistency reliability of the ACQ5. Invariance of factor means across subgroups was assessed. RESULTS A one-factor construct with residual correlations for the ACQ5 was an excellent fit to the data in all subgroups (Root Mean Square Error Approximation 0.03 [90%CI 0.02,0.05], p-close fit 0.93, Comparative Fit Index 1.00, Tucker Lewis Index 1.00}. Expected item responses were consistent for Caucasian and non-Caucasian patients with the same absolute level of symptom control. There was some evidence that females and younger adults reported wakening more frequently during the night than males and older adults respectively with the same absolute level of symptom control (p<0.001). However approximate measurement invariance was tenable and any failure to observe strong measurement invariance had minimal impact when comparing mean levels of asthma symptom control between patients of different sexes or ages. Average levels of asthma symptom control were lower for non-Caucasians (p = 0.001), females (p<0.01)and increased with age (p<0.01). Reliability of the instrument was high (over 88%) in all subgroups studied. CONCLUSION The ACQ5 is informative in comparing levels of symptom control between severe asthmatic patients of different ethnicities, sexes and ages. It is important that analyses are replicated in other severe asthma registries to determine whether measurement invariance is observed.
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Affiliation(s)
- Ronald McDowell
- School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
- School of Psychology, Ulster University, Coleraine, United Kingdom
| | - Liam Heaney
- School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
- Belfast Health & Social Care NHS Trust, Belfast, United Kingdom
| | - Thomas Brown
- Portsmouth Hospitals University NHS Trust, Portsmouth, United Kingdom
| | - Brendan Bunting
- School of Psychology, Ulster University, Coleraine, United Kingdom
| | | | | | - Paddy Dennison
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Shoaib Faruqi
- Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
| | - Robin Gore
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - David J. Jackson
- Guy’s Severe Asthma Centre, Guy’s and St Thomas’ Hospitals, London, United Kingdom
- School of Immunology & Microbial Sciences, King’s College London, London, United Kingdom
| | | | - Thomas Pantin
- Wythenshawe Hospital, Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Mitesh Patel
- University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | | | - Salman Siddiqui
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - John Busby
- School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
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McDowell PJ, McDowell R, Busby J, Eastwood MC, Patel PH, Jackson DJ, Mansur A, Patel M, Burhan H, Doe S, Chaudhuri R, Gore R, Dodd JW, Subramanian D, Brown T, Heaney LG. Clinical remission in severe asthma with biologic therapy: an analysis from the UK Severe Asthma Registry. Eur Respir J 2023; 62:2300819. [PMID: 37857423 PMCID: PMC10719453 DOI: 10.1183/13993003.00819-2023] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/05/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Novel biologic therapies have revolutionised the management of severe asthma with more ambitious treatment aims. Here we analyse the definition of clinical remission as a suggested treatment goal and consider the characteristics associated with clinical remission in a large, real-world severe asthma cohort. METHODS This was a retrospective analysis of severe asthma patients registered in the UK Severe Asthma Registry (UKSAR) who met strict national access criteria for biologics. Patients had a pre-biologics baseline assessment and annual review. The primary definition of clinical remission applied included Asthma Control Questionnaire (ACQ)-5 <1.5 and no oral corticosteroids for disease control and forced expiratory volume in 1 s above lower limit of normal or no more than 100 mL less than baseline. RESULTS 18.3% of patients achieved the primary definition of remission. The adjusted odds of remission on biologic therapy were 7.44 (95% CI 1.73-31.95)-fold higher in patients with type 2 (T2)-high biomarkers. The adjusted odds of remission were lower in patients who were female (OR 0.61, 95% CI 0.45-0.93), obese (OR 0.49, 95% CI 0.24-0.65) or had ACQ-5 ≥1.5 (OR 0.19, 95% CI 0.12-0.31) pre-biologic therapy. The likelihood of remission reduced by 14% (95% CI 0.76-0.97) for every 10-year increase in disease duration. 12-21% of the cohort attained clinical remission depending on the definition applied; most of those who did not achieve remission failed to meet multiple criteria. CONCLUSIONS 18.3% of patients achieved the primary definition of clinical remission. Remission was more likely in T2-high biomarker patients with shorter duration of disease and less comorbidity. Further research on the optimum time to commence biologics in severe asthma is required.
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Affiliation(s)
- P. Jane McDowell
- Wellcome Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
- Belfast Health and Social Care NHS Trust, Belfast, UK
| | - Ron McDowell
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - John Busby
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - M. Chad Eastwood
- Wellcome Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
- Belfast Health and Social Care NHS Trust, Belfast, UK
| | | | - David J. Jackson
- Guy's Severe Asthma Centre, Guy's Hospital, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Adel Mansur
- University of Birmingham and Heartlands Hospital, Birmingham, UK
| | - Mitesh Patel
- Department of Respiratory Medicine, University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | | | - Simon Doe
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Rekha Chaudhuri
- NHS Greater Glasgow and Clyde Health Board, Gartnavel Hospital, Glasgow, UK
| | - Robin Gore
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - James W. Dodd
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Deepak Subramanian
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | | | - Liam G. Heaney
- Wellcome Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
- Belfast Health and Social Care NHS Trust, Belfast, UK
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Apps LD, Chantrell S, Majd S, Eglinton E, Singh SJ, Murphy AC, Green RH, Hudson N, Bradding P, Evans RA. Enabling Adults With Severe Asthma to Exercise: A Qualitative Examination of the Challenges for Patients and Health Care Professionals. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3435-3444.e2. [PMID: 37453572 DOI: 10.1016/j.jaip.2023.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 06/29/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Adults living with severe asthma have lower physical activity levels, particularly high-intensity physical activity, compared with their healthy peers. Physical inactivity is associated with increased morbidity and mortality. OBJECTIVE To understand patient and health care professional attitudes toward exercise and physical activity to inform future strategies for the improvement of healthy lifestyle behaviors, including exercise. METHODS Participants recruited from a specialist difficult asthma service were interviewed individually, and health care professionals (HCPs) from primary care, secondary care, and a tertiary center were invited to attend focus groups. Interviews and focus groups were transcribed verbatim. We performed thematic analysis on interviews and focus groups separately, followed by an adapted framework analysis to analyze datasets together. RESULTS Twenty-nine people with severe asthma participated in a semi-structured interview. A total of 51 HCPs took part in eight focus groups across the East Midlands, United Kingdom. Final analysis resulted in three major themes: barriers to exercise and exercise counseling - in which patients and HCPs identified disease and non-disease factors affecting those living with severe asthma; attitudes toward HCP support for exercise - highlighting education needs for HCPs and preference for supervised exercise programs; and areas for system improvement in supporting patients and HCPs - challenges exist across health sectors that limit patient support are described. CONCLUSIONS Patients identified the important role of HCPs in supporting and advising on lifestyle change. Despite a preference for supervised exercise programs, both patient and HCP barriers existed. To meet patients' varied support needs, improved integration of services is required and HCP skills need extending.
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Affiliation(s)
- Lindsay D Apps
- Centre for Exercise and Rehabilitation Science, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; NIHR Leicester Biomedical Research Centre-Respiratory Theme, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; School of Applied Social Sciences, De Montfort University, Leicester, United Kingdom
| | - Stacey Chantrell
- Centre for Exercise and Rehabilitation Science, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; NIHR Leicester Biomedical Research Centre-Respiratory Theme, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Sally Majd
- Centre for Exercise and Rehabilitation Science, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; NIHR Leicester Biomedical Research Centre-Respiratory Theme, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Medicine, Thoracic Surgery and Allergy, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Science, University of Leicester, Leicester
| | | | - Sally J Singh
- Centre for Exercise and Rehabilitation Science, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; NIHR Leicester Biomedical Research Centre-Respiratory Theme, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Medicine, Thoracic Surgery and Allergy, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Science, University of Leicester, Leicester
| | - Anna C Murphy
- NIHR Leicester Biomedical Research Centre-Respiratory Theme, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Medicine, Thoracic Surgery and Allergy, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; School of Pharmacy, De Montfort University, Leicester, United Kingdom
| | - Ruth H Green
- NIHR Leicester Biomedical Research Centre-Respiratory Theme, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Medicine, Thoracic Surgery and Allergy, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Science, University of Leicester, Leicester
| | - Nicky Hudson
- School of Applied Social Sciences, De Montfort University, Leicester, United Kingdom
| | - Peter Bradding
- NIHR Leicester Biomedical Research Centre-Respiratory Theme, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Medicine, Thoracic Surgery and Allergy, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Science, University of Leicester, Leicester
| | - Rachael A Evans
- Centre for Exercise and Rehabilitation Science, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; NIHR Leicester Biomedical Research Centre-Respiratory Theme, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Medicine, Thoracic Surgery and Allergy, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Science, University of Leicester, Leicester.
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Laurenzo SA, Townsend EA, Lane Starr NM, Wollet LJ, Castro M, Jarjour NN, Sorkness CA, Lee KE, Denlinger LC. Development and Dynamic Responsiveness of the Acute Asthma Exacerbation Survey in Patients With Moderate to Severe Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3425-3434.e4. [PMID: 37453571 PMCID: PMC11000541 DOI: 10.1016/j.jaip.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The recall periods and response scales of existing surveys of asthma control are poorly suited for studying acute exacerbations. OBJECTIVE To develop an instrument able to predict exacerbations after the onset of acute symptoms and with a recall window sufficiently short to study recovery. METHODS We developed the six-item Acute Asthma Exacerbation Survey (AAES). Data were collected at baseline, acute, and recovery visits within an established longitudinal protocol for participants with severe asthma. Participants scheduled acute study visits at the first sign of a cold. Nasal lavage samples and lung function measurements were also collected. The AAES data were analyzed using Cronbach α, Spearman correlations, and Kruskal-Wallace methods. We used logistic regression for predictors of bursts of oral corticosteroids (OCS). RESULTS Of 130 participants studied at baseline, 52 returned for an acute visit. The AAES scores were elevated at the acute visit and returned to baseline after recovery independently of respiratory virus detection. Cronbach α for the AAES was 0.853, 0.822, and 0.889 at the three respective visits. Compared with participants not needing burst OCS, those with exacerbations had higher acute AAES scores (16 [13.5-18] vs 11.5 [8.2-14], median [interquartile range]; P = .017) and a larger reduction from baseline in lung function. For each 3-point increase in AAES scores, the odds ratio for burst OCS use was 1.64 (95% CI, 1.04-2.57; P = .030). CONCLUSIONS The AAES is internally consistent and dynamically responsive during acute asthma exacerbations. Additional validation studies are warranted to support future trials and aid in clinical decision-making.
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Affiliation(s)
- Scott A Laurenzo
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Elizabeth A Townsend
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis; Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Nicole M Lane Starr
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Lori J Wollet
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Mario Castro
- Department of Internal Medicine, University of Kansas-Kansas City, Kansas City, Kan
| | - Nizar N Jarjour
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Christine A Sorkness
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis; Pharmacy Practice and Translational Research Division, University of Wisconsin School of Pharmacy, Madison, Wis
| | - Kristine E Lee
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Loren C Denlinger
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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Fiocchi AG, Phipatanakul W, Zeiger RS, Durrani SR, Cole J, Msihid J, Gall R, Jacob-Nara JA, Deniz Y, Rowe PJ, Lederer DJ, Hardin M, Zhang Y, Khan AH. Dupilumab leads to better-controlled asthma and quality of life in children: the VOYAGE study. Eur Respir J 2023; 62:2300558. [PMID: 37734856 PMCID: PMC10620476 DOI: 10.1183/13993003.00558-2023] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/13/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Dupilumab has shown long-term treatment benefits in children with uncontrolled asthma. We assessed in more detail the impact of dupilumab on asthma control and health-related quality of life (HRQoL) in children and their caregivers. METHODS Children aged 6-11 years with uncontrolled moderate-to-severe type 2 asthma (baseline blood eosinophils ≥150 cells·µL-1 or fractional exhaled nitric oxide ≥20 ppb; n=350) were treated with dupilumab or placebo for 52 weeks in the VOYAGE study. Primary outcomes of these analyses were asthma control (change from baseline in Asthma Control Questionnaire 7 Interviewer-Administered (ACQ-7-IA) and achieving a clinically meaningful response of ≥0.5 points); proportion of patients achieving well-controlled asthma or better (ACQ-7-IA ≤0.75 points); effect on patients' (Standardised Paediatric Asthma Quality of Life Questionnaire Interviewer-Administered (PAQLQ(S)-IA)) and caregivers' (Paediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ)) HRQoL; and allergic rhinitis-related QoL. RESULTS Dupilumab versus placebo significantly improved children's ACQ-7-IA scores by week 4 with sustained improvements through week 52 (least squares mean difference at week 52: -0.44, 95% CI -0.59- -0.30; p<0.0001); a higher proportion achieved a clinically meaningful response (week 52: 86% versus 75%; p=0.0051). At weeks 24 and 52, more children who received dupilumab achieved well-controlled asthma (ACQ-7-IA ≤0.75 points: 61% versus 43%; p=0.0001 and 70% versus 46%; p<0.0001, respectively). Significant improvements in PAQLQ(S)-IA and PACQLQ scores were observed by week 52. CONCLUSIONS In children aged 6-11 years with moderate-to-severe type 2 asthma, dupilumab treatment was associated with rapid, sustained improvements in asthma control. HRQoL was significantly improved for children and their caregivers.
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Affiliation(s)
- Alessandro G Fiocchi
- Translational Research in Paediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Wanda Phipatanakul
- Department of Allergy and Immunology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Robert S Zeiger
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | | | | | | | - Rebecca Gall
- Regeneron Pharmaceuticals Inc., Tarrytown, NY, USA
| | | | - Yamo Deniz
- Regeneron Pharmaceuticals Inc., Tarrytown, NY, USA
| | | | | | | | - Yi Zhang
- Regeneron Pharmaceuticals Inc., Tarrytown, NY, USA
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Kaminsky DA, He J, Henderson R, Dixon AE, Irvin CG, Mastronarde J, Smith LJ, Sugar EA, Wise RA, Holbrook JT. Bronchodilator response does not associate with asthma control or symptom burden among patients with poorly controlled asthma. Respir Med 2023; 218:107375. [PMID: 37536444 DOI: 10.1016/j.rmed.2023.107375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE The purpose of this study was to determine how four different definitions of bronchodilator response (BDR) relate to asthma control and asthma symptom burden in a large population of participants with poorly controlled asthma. PROCEDURES We examined the baseline change in FEV1 and FVC in response to albuterol among 931 participants with poorly controlled asthma pooled from three clinical trials conducted by the American Lung Association - Airways Clinical Research Centers. We defined BDR based on four definitions and analyzed the association of each with asthma control as measured by the Asthma Control Test or Asthma Control Questionnaire, and asthma symptom burden as measured by the Asthma Symptom Utility Index. MAIN FINDINGS A BDR was seen in 31-42% of all participants, depending on the definition used. There was good agreement among responses (kappa coefficient 0.73 to 0.87), but only 56% of participants met all four definitions for BDR. A BDR was more common in men than women, in Blacks compared to Whites, in non-smokers compared to smokers, and in non-obese compared to obese participants. Among those with poorly controlled asthma, 35% had a BDR compared to 25% of those with well controlled asthma, and among those with a high symptom burden, 34% had a BDR compared to 28% of those with a low symptom burden. After adjusting for age, sex, height, race, obesity and baseline lung function, none of the four definitions was associated with asthma control or symptom burden. CONCLUSION A BDR is not associated with asthma control or symptoms in people with poorly controlled asthma, regardless of the definition of BDR used. These findings question the clinical utility of a BDR in assessing asthma control and symptoms.
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Affiliation(s)
- David A Kaminsky
- Pulmonary and Critical Care, University of Vermont Larner College of Medicine, Burlington, VT, USA.
| | - Jiaxian He
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert Henderson
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anne E Dixon
- Pulmonary and Critical Care, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Charles G Irvin
- Pulmonary and Critical Care, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | | | - Lewis J Smith
- Northwestern University School of Medicine, Chicago, IL, USA
| | - Elizabeth A Sugar
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert A Wise
- Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Janet T Holbrook
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Alvarado-Vazquez PA, Mendez-Enriquez E, Salomonsson M, Waern I, Janson C, Wernersson S, Malinovschi A, Hallgren J. Circulating mast cell progenitors increase during natural birch pollen exposure in allergic asthma patients. Allergy 2023; 78:2959-2968. [PMID: 37615432 DOI: 10.1111/all.15860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/02/2023] [Accepted: 07/15/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Mast cells (MCs) develop from a rare population of peripheral blood circulating MC progenitors (MCps). Here, we investigated whether the frequency of circulating MCps is altered in asthma patients sensitized to birch pollen during pollen season, compared to out of season. METHODS Asthma patients were examined during birch pollen season in late April to early June (May), and out of season in November-January. Spirometry measurements, asthma and allergy-related symptoms, asthma control questionnaire (ACQ), and asthma control test (ACT) scores were assessed at both time points. The MCp frequency was determined by flow cytometry in ficoll-separated blood samples from patients with positive birch pollen-specific IgE, and analyzed in relation to basic and disease parameters. RESULTS The frequency of MCps per liter of blood was higher in May than in November (p = .004), particularly in women (p = .009). Patients that reported moderate to severe asthma symptoms (<.0001), nose or eye symptoms (p = .02; p = .01), or reduced asthma control (higher ACQ, p = .01) had higher MCp frequency in May than those that did not report this. These associations remained significant after adjusting for sex and BMI. The change in asthma control to a lower ACT score in May correlated with an increase in MCp frequency in May (p = .006, rho = 0.46). CONCLUSIONS The data suggest that the frequency of MCps increases in symptomatic patients with allergic asthma. Our results unravel a link between asthma symptoms and circulating MCps, and bring new insight into the impact of natural allergen exposure on the expansion of MCs.
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Affiliation(s)
| | - Erika Mendez-Enriquez
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Maya Salomonsson
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Ida Waern
- Department of Anatomy, Physiology and Biochemistry, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Christer Janson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Sara Wernersson
- Department of Anatomy, Physiology and Biochemistry, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | | | - Jenny Hallgren
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
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Jin FD, Wang J, Deng SJ, Song WJ, Zhang X, Wang CY, Gao SY, Chung KF, Yang Y, Vertigan AE, Luo FM, Birring SS, Li WM, Liu D, Wang G. Interaction effect of chronic cough and ageing on increased risk of exacerbation in patients with asthma: a prospective cohort study in a real-world setting. ERJ Open Res 2023; 9:00461-2023. [PMID: 38152080 PMCID: PMC10752289 DOI: 10.1183/23120541.00461-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/26/2023] [Indexed: 12/29/2023] Open
Abstract
Background Older adults with asthma have the greatest burden and worst outcomes, and there is increasing evidence that chronic cough (CC) is associated with asthma severity and poor prognosis. However, the clinical characteristics of older adult patients with both asthma and CC remain largely unknown. Methods Participants with stable asthma underwent two cough assessments within 3 months to define the presence of CC. Patients were divided into four groups based on CC and age (cut-off ≥60 years). Multidimensional assessment was performed at baseline, followed by a 12-month follow-up to investigate asthma exacerbations. Logistic regression models were used to explore the interaction effect of CC and age on asthma control and exacerbations. Results In total, 310 adult patients were prospectively recruited and divided into four groups: older CC group (n=46), older non-CC group (n=20), younger CC group (n=112) and younger non-CC group (n=132). Compared with the younger non-CC group, the older CC group had worse asthma control and quality of life and increased airflow obstruction. The older CC group showed an increase in moderate-to-severe exacerbations during the 12-month follow-up. There was a significant interaction effect of CC and ageing on the increased moderate-to-severe exacerbations (adjusted risk ratio 2.36, 95% CI 1.47-3.30). Conclusion Older asthma patients with CC have worse clinical outcomes, including worse asthma control and quality of life, increased airway obstruction and more frequent moderate-to-severe exacerbations, which can be partly explained by the interaction between CC and ageing.
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Affiliation(s)
- Fan Ding Jin
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
- State Key Laboratory of Respiratory Health and Multimorbidity, Sichuan University, Chengdu, China
- Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
- These authors contributed equally
| | - Ji Wang
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
- State Key Laboratory of Respiratory Health and Multimorbidity, Sichuan University, Chengdu, China
- Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
- These authors contributed equally
| | - Su Jun Deng
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
- State Key Laboratory of Respiratory Health and Multimorbidity, Sichuan University, Chengdu, China
- Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
| | - Woo-Jung Song
- Airway Sensation and Cough Research Laboratory, Department of Allergy and Clinical Immunology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Xin Zhang
- Division of Internal Medicine, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Chang Yong Wang
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
- State Key Laboratory of Respiratory Health and Multimorbidity, Sichuan University, Chengdu, China
- Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
| | - Si Yang Gao
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
- State Key Laboratory of Respiratory Health and Multimorbidity, Sichuan University, Chengdu, China
- Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
| | - Kian Fan Chung
- Department of Respiratory Medicine, Royal Brompton and Harefield NHS Trust, London, UK
- Experimental Studies Unit, National Heart and Lung Institute, Imperial College London, London, UK
| | - Ye Yang
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
- Department of Thoracic Medical Oncology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, Cancer Hospital affiliate to School of Medicine, Chengdu, China
| | - Anne E. Vertigan
- National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and Treatable Traits, The University of Newcastle, Newcastle, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, Newcastle, Australia
- Speech Pathology, John Hunter Hospital, Newcastle, Australia
| | - Feng Ming Luo
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
- State Key Laboratory of Respiratory Health and Multimorbidity, Sichuan University, Chengdu, China
- Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
| | - Surinder S. Birring
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Wei Min Li
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
- State Key Laboratory of Respiratory Health and Multimorbidity, Sichuan University, Chengdu, China
- Respiratory Microbiome Laboratory, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
| | - Dan Liu
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
- State Key Laboratory of Respiratory Health and Multimorbidity, Sichuan University, Chengdu, China
- Respiratory Microbiome Laboratory, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
| | - Gang Wang
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
- State Key Laboratory of Respiratory Health and Multimorbidity, Sichuan University, Chengdu, China
- Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
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Greenfield N, Becker J, Jariwala S, Wisnivesky J, Federman A, Feldman JM. The relationship between social support, self-efficacy, and asthma outcomes in older adults. J Asthma 2023; 60:1853-1861. [PMID: 36972524 PMCID: PMC10523994 DOI: 10.1080/02770903.2023.2196560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/06/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE There has been a call for research examining factors that influence asthma outcomes in older adults because of the notable disparities observed in this age group. Social support and self-efficacy are resources that factor into asthma outcomes. The current study aimed to examine the relationship between these resources (independently and jointly) and asthma control and quality of life. METHODS Older adults with moderate-severe asthma were recruited from NYC. Data were obtained during in-person interviews via validated measures of social support, asthma self-efficacy, asthma control, and asthma quality of life. Linear regression evaluated self-efficacy in the relationship between social support and asthma outcomes. RESULTS In a sample of 359 older adults (M = 68.04, 47.9% Hispanic, 26.5% Black, and 25.6% other), social support had an inverse association with asthma control. As social support increased, asthma control decreased (β = 0.95, t(356) = -3.13, p = .002). Self-efficacy significantly moderated this relationship (β = 0.01, t(356) = 2.37, p = .018). For individuals with low or moderate asthma self-efficacy, more received social support was associated with worse asthma control (β = -0.33, t(356) = -4.66, p < .0001; β = -0.20, t(356) = -3.21, p = .0014, respectively). For individuals with high self-efficacy, no relationship was found between received social support and asthma control (β = -0.10, t(356)= -1.20, p =.23). For asthma quality of life, higher levels of received social support were associated with worse quality of life (β = -0.88, t(356) = -2.64, p = .009), but this association was not significantly moderated by self-efficacy (β = 0.01, t(356) = 1.90, p = .0582). CONCLUSIONS For older adults with asthma, receiving more social support is associated with worse asthma outcomes, especially for older adults with lower asthma self-efficacy.
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Affiliation(s)
- Naomi Greenfield
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
| | - Jacqueline Becker
- Icahn School of Medicine at Mount Sinai, Division of General Internal Medicine, New York, NY
| | - Sunit Jariwala
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Medicine, Division of Allergy/Immunology, Bronx, NY
| | - Juan Wisnivesky
- Icahn School of Medicine at Mount Sinai, Division of General Internal Medicine, New York, NY
| | - Alex Federman
- Icahn School of Medicine at Mount Sinai, Division of General Internal Medicine, New York, NY
| | - Jonathan M. Feldman
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
- Albert Einstein College of Medicine, Children’s Hospital at Montefiore, Department of Pediatrics, Division of Academic General Pediatrics, Bronx, NY
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Plaza Moral V, Alobid I, Álvarez Rodríguez C, Blanco Aparicio M, Ferreira J, García G, Gómez-Outes A, Garín Escrivá N, Gómez Ruiz F, Hidalgo Requena A, Korta Murua J, Molina París J, Pellegrini Belinchón FJ, Plaza Zamora J, Praena Crespo M, Quirce Gancedo S, Sanz Ortega J, Soto Campos JG. GEMA 5.3. Spanish Guideline on the Management of Asthma. OPEN RESPIRATORY ARCHIVES 2023; 5:100277. [PMID: 37886027 PMCID: PMC10598226 DOI: 10.1016/j.opresp.2023.100277] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
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Affiliation(s)
| | - Isam Alobid
- Otorrinolaringología, Hospital Clinic de Barcelona, España
| | | | | | - Jorge Ferreira
- Hospital de São Sebastião – CHEDV, Santa Maria da Feira, Portugal
| | | | - Antonio Gómez-Outes
- Farmacología clínica, Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, España
| | - Noé Garín Escrivá
- Farmacia Hospitalaria, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | | | - Javier Korta Murua
- Neumología Pediátrica, Hospital Universitario Donostia, Donostia-San, Sebastián, España
| | - Jesús Molina París
- Medicina de familia, semFYC, Centro de Salud Francia, Fuenlabrada, Dirección Asistencial Oeste, Madrid, España
| | | | - Javier Plaza Zamora
- Farmacia comunitaria, Farmacia Dr, Javier Plaza Zamora, Mazarrón, Murcia, España
| | | | | | - José Sanz Ortega
- Alergología Pediátrica, Hospital Católico Universitario Casa de Salud, Valencia, España
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Chipps BE, Israel E, Beasley R, Panettieri RA, Albers FC, Rees R, Dunsire L, Danilewicz A, Johnsson E, Cappelletti C, Papi A. Albuterol-Budesonide Pressurized Metered Dose Inhaler in Patients With Mild-to-Moderate Asthma: Results of the DENALI Double-Blind Randomized Controlled Trial. Chest 2023; 164:585-595. [PMID: 37003355 DOI: 10.1016/j.chest.2023.03.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/16/2023] [Accepted: 03/26/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND In the phase 3 MANDALA trial, as-needed albuterol-budesonide pressurized metered-dose inhaler significantly reduced severe exacerbation risk vs as-needed albuterol in patients with moderate-to-severe asthma receiving inhaled corticosteroid-containing maintenance therapy. This study (DENALI) was conducted to address the US Food and Drug Administration combination rule, which requires a combination product to demonstrate that each component contributes to its efficacy. RESEARCH QUESTION Do both albuterol and budesonide contribute to the efficacy of the albuterol-budesonide combination pressurized metered-dose inhaler in patients with asthma? STUDY DESIGN AND METHODS This phase 3 double-blind trial randomized patients aged ≥ 12 years with mild-to-moderate asthma 1:1:1:1:1 to four-times-daily albuterol-budesonide 180/160 μg or 180/80 μg, albuterol 180 μg, budesonide 160 μg, or placebo for 12 weeks. Dual-primary efficacy end points included change from baseline in FEV1 area under the curve from 0 to 6 h (FEV1 AUC0-6h) over 12 weeks (assessing albuterol effect) and trough FEV1 at week 12 (assessing budesonide effect). RESULTS Of 1,001 patients randomized, 989 were ≥ 12 years old and evaluable for efficacy. Change from baseline in FEV1 AUC0-6h over 12 weeks was greater with albuterol-budesonide 180/160 μg vs budesonide 160 μg (least-squares mean [LSM] difference, 80.7 [95% CI, 28.4-132.9] mL; P = .003). Change in trough FEV1 at week 12 was greater with albuterol-budesonide 180/160 and 180/80 μg vs albuterol 180 μg (LSM difference, 132.8 [95% CI, 63.6-201.9] mL and 120.8 [95% CI, 51.5-190.1] mL, respectively; both P < .001). Day 1 time to onset and duration of bronchodilation with albuterol-budesonide were similar to those with albuterol. The albuterol-budesonide adverse event profile was similar to that of the monocomponents. INTERPRETATION Both monocomponents contributed to albuterol-budesonide lung function efficacy. Albuterol-budesonide was well tolerated, even at regular, relatively high daily doses for 12 weeks, with no new safety findings, supporting its use as a novel rescue therapy. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT03847896; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
| | - Elliot Israel
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Reynold A Panettieri
- Rutgers Institute for Translational Medicine and Science, Child Health Institute of New Jersey, Rutgers, State University of New Jersey, New Brunswick, NJ
| | | | | | - Lynn Dunsire
- BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | | | - Eva Johnsson
- BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | - Alberto Papi
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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Chen W, Tran TN, Sadatsafavi M, Murray R, Wong NCB, Ali N, Ariti C, Bulathsinhala L, Gil EG, FitzGerald JM, Alacqua M, Al-Ahmad M, Altraja A, Al-Lehebi R, Bhutani M, Bjermer L, Bjerrum AS, Bourdin A, von Bülow A, Busby J, Canonica GW, Carter V, Christoff GC, Cosio BG, Costello RW, Fonseca JA, Gibson PG, Yoo KH, Heaney LG, Heffler E, Hew M, Hilberg O, Hoyte F, Iwanaga T, Jackson DJ, Jones RC, Koh MS, Kuna P, Larenas-Linnemann D, Lehmann S, Lehtimäki L, Lyu J, Mahboub B, Maspero J, Menzies-Gow AN, Newell A, Sirena C, Papadopoulos NG, Papaioannou AI, Perez-de-Llano L, Perng Steve DW, Peters M, Pfeffer PE, Porsbjerg CM, Popov TA, Rhee CK, Salvi S, Taillé C, Taube C, Torres-Duque CA, Ulrik C, Ra SW, Wang E, Wechsler ME, Price DB. Impact of Initiating Biologics in Patients With Severe Asthma on Long-Term Oral Corticosteroids or Frequent Rescue Steroids (GLITTER): Data From the International Severe Asthma Registry. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2732-2747. [PMID: 37301430 DOI: 10.1016/j.jaip.2023.05.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Effectiveness of biologics has neither been established in patients with high oral corticosteroid exposure (HOCS) nor been compared with effectiveness of continuing with HOCS alone. OBJECTIVE To examine the effectiveness of initiating biologics in a large, real-world cohort of adult patients with severe asthma and HOCS. METHODS This was a propensity score-matched, prospective cohort study using data from the International Severe Asthma Registry. Between January 2015 and February 2021, patients with severe asthma and HOCS (long-term OCSs for ≥1 year or ≥4 courses of rescue OCSs within a 12-month period) were identified. Biologic initiators were identified and, using propensity scores, matched 1:1 with noninitiators. The impact of biologic initiation on asthma outcomes was assessed using generalized linear models. RESULTS We identified 996 matched pairs of patients. Both groups improved over the 12-month follow-up period, but improvement was greater for biologic initiators. Biologic initiation was associated with a 72.9% reduction in the average number of exacerbations per year versus noninitiators (0.64 vs 2.06; rate ratio, 0.27 [95% CI, 0.10-0.71]). Biologic initiators were 2.2 times more likely than noninitiators to take a daily long-term OCS dose of less than 5 mg (risk probability, 49.6% vs 22.5%; P = .002) and had a lower risk of asthma-related emergency department visits (relative risk, 0.35 [95% CI, 0.21-0.58]; rate ratio, 0.26 [0.14-0.48]) and hospitalizations (relative risk, 0.31 [95% CI, 0.18-0.52]; rate ratio, 0.25 [0.13-0.48]). CONCLUSIONS In a real-world setting, including patients with severe asthma and HOCS from 19 countries, and within an environment of clinical improvement, initiation of biologics was associated with further improvements across multiple asthma outcomes, including exacerbation rate, OCS exposure, and health care resource utilization.
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Affiliation(s)
- Wenjia Chen
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | | | - Mohsen Sadatsafavi
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ruth Murray
- Optimum Patient Care Global, Cambridge, United Kingdom
| | | | - Nasloon Ali
- Optimum Patient Care Global, Cambridge, United Kingdom; Observational and Pragmatic Research Institute, Singapore
| | - Con Ariti
- Optimum Patient Care Global, Cambridge, United Kingdom; Observational and Pragmatic Research Institute, Singapore
| | - Lakmini Bulathsinhala
- Optimum Patient Care Global, Cambridge, United Kingdom; Observational and Pragmatic Research Institute, Singapore
| | | | - J Mark FitzGerald
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Mona Al-Ahmad
- Microbiology Department, Faculty of Medicine, Kuwait University, Al-Rashed Allergy Center, Ministry of Health, Kuwait City, Kuwait
| | - Alan Altraja
- Department of Pulmonology, University of Tartu and Lung Clinic, Tartu University Hospital, Tartu, Estonia
| | - Riyad Al-Lehebi
- Department of Pulmonology, King Fahad Medical City, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Mohit Bhutani
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Leif Bjermer
- Respiratory Medicine and Allergology, Department of Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
| | - Anne-Sofie Bjerrum
- Department of Respiratory Medicine and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Arnaud Bourdin
- PhyMedExp, Univ Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Anna von Bülow
- Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark
| | - John Busby
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Victoria Carter
- Optimum Patient Care Global, Cambridge, United Kingdom; Observational and Pragmatic Research Institute, Singapore
| | | | - Borja G Cosio
- Son Espases University Hospital-IdISBa-Ciberes, Mallorca, Spain
| | - Richard W Costello
- Department of Respiratory Medicine, RCSI Clinical Research Centre, Smurfit Building Beaumont Hospital, Dublin, Ireland
| | - João A Fonseca
- Health Information and Decision Sciences Department (MEDCIDS) & Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine of University of Porto, Porto, Portugal
| | - Peter G Gibson
- Australian Severe Asthma Network, Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, New South Wales, Australia; Department of Respiratory and Sleep Medicine, Hunter Medical Research Institute, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Kwang-Ha Yoo
- KonKuk University School of Medicine, Seoul, Korea
| | - Liam G Heaney
- Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
| | - Enrico Heffler
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia; Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ole Hilberg
- Medical Department, Vejle University Hospital, Vejle, Denmark
| | - Flavia Hoyte
- Division of Allergy & Clinical Immunology, Department of Medicine, National Jewish Health, Denver, Colo; Division of Allergy & Clinical Immunology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo
| | - Takashi Iwanaga
- Center for General Medical Education and Clinical Training, Kindai University Hospital, Osakasayama, Japan
| | - David J Jackson
- UK Severe Asthma Network and National Registry, Guy's and St Thomas' NHS Trust, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Rupert C Jones
- Research and Knowledge Exchange, Plymouth Marjon University, Plymouth, United Kingdom
| | - Mariko Siyue Koh
- Respiratory & Critical Care Medicine, Singapore General Hospital, Singapore; SingHealth Duke-NUS Lung Centre, Singapore
| | - Piotr Kuna
- Division of Internal Medicine, Asthma and Allergy Medical University of Łódź, Łódź, Poland
| | | | - Sverre Lehmann
- Section of Thoracic Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Lauri Lehtimäki
- Allergy Centre, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Juntao Lyu
- Observational and Pragmatic Research Institute, Singapore; Optimum Patient Care, Brisbane, Queensland, Australia
| | - Bassam Mahboub
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates; Rashid Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Jorge Maspero
- Clinical Research for Allergy and Respiratory Medicine, CIDEA Foundation, Buenos Aires, Argentina; University Career of Specialists in Allergy and Clinical Immunology at the Buenos Aires University School of Medicine, Buenos Aires, Argentina
| | | | - Anthony Newell
- Observational and Pragmatic Research Institute, Singapore; Optimum Patient Care, Brisbane, Queensland, Australia
| | | | - Nikolaos G Papadopoulos
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, United Kingdom; Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece
| | - Andriana I Papaioannou
- 2nd Respiratory Medicine Department, National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Luis Perez-de-Llano
- Pneumology Service, Lucus Augusti University Hospital, EOXI Lugo, Monforte, Cervo, Lugo, Spain; Biodiscovery Research Group, Health Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
| | - Diahn-Warng Perng Steve
- Division of Clinical Respiratory Physiology, Chest Department, Taipei Veterans General Hospital, Taipei, Taiwan; COPD Assembly of the Asian Pacific Society of Respirology, Tokyo, Japan
| | - Matthew Peters
- Department of Thoracic Medicine, Concord Hospital, Sydney, New South Wales, Australia
| | - Paul E Pfeffer
- Department of Respiratory Medicine, Barts Health NHS Trust, London, United Kingdom; Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Celeste M Porsbjerg
- Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Todor A Popov
- University Hospital "Sv. Ivan Rilski," Sofia, Bulgaria
| | - Chin Kook Rhee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sundeep Salvi
- Pulmocare Research and Education Foundation, Pune, Maharashtra, India
| | - Camille Taillé
- Department of Respiratory Diseases, Bichat Hospital, AP-HP Nord-Université de Paris, Paris, France
| | - Christian Taube
- Department of Pulmonary Medicine, University Medical Center Essen-Ruhrlandklinik, Essen, Germany
| | - Carlos A Torres-Duque
- CINEUMO, Respiratory Research Center, Fundación Neumológica Colombiana, Bogotá, Colombia
| | - Charlotte Ulrik
- Department of Respiratory Medicine, Copenhagen University Hospital-Hvidovre, Hvidovre, Denmark
| | - Seung-Won Ra
- Division of Pulmonology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Eileen Wang
- Division of Allergy & Clinical Immunology, Department of Medicine, National Jewish Health, Denver, Colo; Division of Allergy & Clinical Immunology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo
| | - Michael E Wechsler
- NJH Cohen Family Asthma Institute, Department of Medicine, National Jewish Health, Denver, Colo
| | - David B Price
- Optimum Patient Care Global, Cambridge, United Kingdom; Observational and Pragmatic Research Institute, Singapore; Division of Applied Health Sciences, Centre of Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom.
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Lin T, Pham J, Denton E, Lee J, Hore-Lacy F, Sverrild A, Stojanovic S, Tay TR, Murthee KG, Radhakrishna N, Dols M, Bondarenko J, Mahoney J, O'Hehir RE, Dabscheck E, Hew M. Trait profiles in difficult-to-treat asthma: Clinical impact and response to systematic assessment. Allergy 2023; 78:2418-2427. [PMID: 36940306 DOI: 10.1111/all.15719] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/12/2023] [Accepted: 01/31/2023] [Indexed: 03/22/2023]
Abstract
BACKGROUND Multidisciplinary systematic assessment improves outcomes in difficult-to-treat asthma, but without clear response predictors. Using a treatable-traits framework, we stratified patients by trait profile, examining clinical impact and treatment responsiveness to systematic assessment. METHODS We performed latent class analysis using 12 traits on difficult-to-treat asthma patients undergoing systematic assessment at our institution. We examined Asthma Control Questionnaire (ACQ-6) and Asthma Quality of Life Questionnaire (AQLQ) scores, FEV1 , exacerbation frequency, and maintenance oral corticosteroid (mOCS) dose, at baseline and following systematic assessment. RESULTS Among 241 patients, two airway-centric profiles were characterized by early-onset with allergic rhinitis (n = 46) and adult onset with eosinophilia/chronic rhinosinusitis (n = 60), respectively, with minimal comorbid or psychosocial traits; three non-airway-centric profiles exhibited either comorbid (obesity, vocal cord dysfunction, dysfunctional breathing) dominance (n = 51), psychosocial (anxiety, depression, smoking, unemployment) dominance (n = 72), or multi-domain impairment (n = 12). Compared to airway-centric profiles, non-airway-centric profiles had worse baseline ACQ-6 (2.7 vs. 2.2, p < .001) and AQLQ (3.8 vs. 4.5, p < .001) scores. Following systematic assessment, the cohort showed overall improvements across all outcomes. However, airway-centric profiles had more FEV1 improvement (5.6% vs. 2.2% predicted, p < .05) while non-airway-centric profiles trended to greater exacerbation reduction (1.7 vs. 1.0, p = .07); mOCS dose reduction was similar (3.1 mg vs. 3.5 mg, p = .782). CONCLUSION Distinct trait profiles in difficult-to-treat asthma are associated with different clinical outcomes and treatment responsiveness to systematic assessment. These findings yield clinical and mechanistic insights into difficult-to-treat asthma, offer a conceptual framework to address disease heterogeneity, and highlight areas responsive to targeted intervention.
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Affiliation(s)
- Tiffany Lin
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Jonathan Pham
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Eve Denton
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Joy Lee
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Fiona Hore-Lacy
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Asger Sverrild
- Department of Respiratory Medicine, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Stephanie Stojanovic
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore City, Singapore
| | | | - Naghmeh Radhakrishna
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Monique Dols
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Janet Bondarenko
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Janine Mahoney
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Robyn E O'Hehir
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Eli Dabscheck
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Yun HJ, Eom SY, Hahn YS. Assessing Asthma Control by Impulse Oscillometry and Fractional Expiratory Nitric Oxide in Children With Normal Spirometry. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2822-2829.e1. [PMID: 37178768 DOI: 10.1016/j.jaip.2023.04.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 04/03/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Because spirometric parameters fail to address current status of asthma in some patients, additional tests are required for better evaluation of asthma. OBJECTIVE We aimed to test the ability of impulse oscillometry (IOS) and fractional expiratory nitric oxide (FeNO) in identifying inadequately controlled asthma (ICA) that was not uncovered by spirometry. METHODS Recruited asthmatic children between ages of 8 and 16 years underwent spirometry, IOS, and FeNO measurements on the same day. Only subjects who had spirometric indices within normal range were included. Asthma Control Questionnaire-6 scores of 0.75 or lower and greater than 0.75 indicated well-controlled asthma (WCA) and ICA. Percent predicted values of IOS parameters and IOS reference values for upper and lower limits of normal (>95th and <5th percentiles, respectively) were calculated on the basis of previously published equations. RESULTS There were no significant differences in all spirometric indices between the WCA (n = 59) and the ICA (n = 101) groups. The % predicted values of IOS parameters except resistance at 20 Hz (R20) were significantly different between the 2 groups. Receiver operating characteristic analysis showed that the highest and lowest areas under the curve were 0.81 and 0.67 for the difference between the resistances at 5 Hz and 20 Hz (R5-R20) and R20 in discrimination of ICA versus WCA. The areas under the curve for IOS parameters were improved by combination with FeNO. The better discriminative ability of IOS was also supported by the higher values of the concordance index for the resistance at 5 Hz (R5), R5-R20, the reactance at 5 Hz (X5), and the resonant frequency of reactance than those for spirometric parameters. Compared with those with normal values, subjects with abnormal IOS parameters or high FeNO had significantly higher odds of having ICA. CONCLUSIONS The IOS parameters and FeNO were shown to be useful in identifying children with ICA when spirometry was normal.
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Affiliation(s)
- Hee-Jeong Yun
- Department of Pediatrics, College of Medicine and Medical Research Institute, Chungbuk National University, Cheongju, Korea
| | - Sang-Yong Eom
- Department of Preventive Medicine, College of Medicine and Medical Research Institute, Chungbuk National University, Cheongju, Korea
| | - Youn-Soo Hahn
- Department of Pediatrics, College of Medicine and Medical Research Institute, Chungbuk National University, Cheongju, Korea.
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de Lima FF, Lunardi AC, Pinheiro DHA, Carvalho-Pinto RM, Stelmach R, Giavina-Bianchi P, Agondi RC, Carvalho CR. Identifying the Characteristics of Responders and Nonresponders in a Behavioral Intervention to Increase Physical Activity Among Patients With Moderate to Severe Asthma: Protocol for a Prospective Pragmatic Study. JMIR Res Protoc 2023; 12:e49032. [PMID: 37651174 PMCID: PMC10502597 DOI: 10.2196/49032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Previous research has suggested that most adults improve their asthma control after a short-term behavioral intervention program to increase physical activity in daily life (PADL). However, the characteristics of individuals who respond and do not respond to this intervention and the medium-term response remain unknown. OBJECTIVE This study aims to (1) identify the characteristics of adult responders and nonresponders with asthma to a behavioral intervention to increase physical activity and (2) evaluate the functional and clinical benefits in the medium term. METHODS This prospective pragmatic study will include adults with moderate to severe asthma who enroll in a behavioral intervention. All individuals will receive an educational program and an 8-week intervention to increase PADL (1 time/wk; up to 90 min/session). The educational program will be conducted in a class setting through group discussions and video presentations. Behavioral interventions will be based on the transtheoretical model using counseling, incentives, and individual feedback aiming to increase participation in physical activity. Motivational interviewing and guidelines for overcoming barriers will be used to stimulate individuals to reach their goals. Pre- and postintervention assessments will include the following: PADL (triaxial accelerometry), body composition (octopolar bioimpedance), barriers to PADL (questionnaire), clinical asthma control (Asthma Control Questionnaire), quality of life (Asthma Quality of Life Questionnaire), anxiety and depression levels (Hospital Anxiety and Depression Scale), and exacerbations. "Responders" to the intervention will be defined as those who demonstrate an increase in the number of daily steps (≥2500). RESULTS In December 2021, the clinical trial registration was approved. Recruitment and data collection for the trial is ongoing, and the results of this study are likely to be published in late 2024. CONCLUSIONS The intervention will likely promote different effects according to the clinical characteristics of the individuals, including asthma control, age, anxiety and depression levels, obesity, and several comorbidities. Identifying individuals who respond or do not respond to behavioral interventions to increase PADL will help clinicians prescribe specific interventions to adults with asthma. TRIAL REGISTRATION ClinicalTrials.gov NCT05159076; https://clinicaltrials.gov/ct2/show/NCT05159076. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/49032.
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Affiliation(s)
| | - Adriana Claudia Lunardi
- Department of Physical Therapy, School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | | | - Rafael Stelmach
- Pulmonary Division, Instituto do Coração, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Pedro Giavina-Bianchi
- Department of Clinical Immunology and Allergy, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Rosana Câmara Agondi
- Department of Clinical Immunology and Allergy, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Celso Rf Carvalho
- Department of Physical Therapy, School of Medicine, University of São Paulo, São Paulo, Brazil
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Linton S, Xu K, Hossenbaccus L, Botting H, Garvey S, Sunavsky A, Steacy LM, Tripp DA, Ellis AK. Anxiety in adults with asthma during the coronavirus disease 2019 pandemic: a Canadian perspective. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:73. [PMID: 37612771 PMCID: PMC10463471 DOI: 10.1186/s13223-023-00833-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/06/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Asthma is a chronic airway inflammatory disease that affects millions of Canadians and often contributes to higher levels of anxiety among patients. Since the coronavirus disease 2019 (COVID-19) pandemic was a time of increased anxiety and fear among the Canadian population, it was thought that those with asthma may experience heightened anxiety levels due to uncertain access to care, the potential to misinterpret asthma symptoms for symptoms of COVID-19 (or vice versa), and the concern about being treated differently by those around them when experiencing asthma symptoms. Therefore, this study sought to perform a cross-sectional analysis of the asthma-anxiety relationship in adults with and without asthma in the unique context of the COVID-19 pandemic from a Canadian perspective. METHODS This study employed the COVID-19 Associated Anxiety in Allergic Rhinitis and Asthma patients Experiencing Symptoms (CAAARES) survey, consisting of COVID-19-specific questions, the Generalized Anxiety Disorder Assessment-7 (GAD-7) and the Asthma Control Questionnaire-6 (ACQ-6). Data collection occurred through the Qualtrics XM platform and data analyses were conducted with the IBM SPSS Statistics 28 software. RESULTS A total of 741 valid responses were collected (asthma group, n = 244; control group, n = 497). 31.6% and 26.2% of respondents in the asthma and control groups, respectively, met the diagnostic criteria for GAD. There was no significant difference (p = .067) in mean GAD-7 scores between the two groups. A Hierarchal Multiple Regression (HMR) model was developed, and neither asthma status nor ACQ-6 score had a significant predictive effect on the GAD-7 score. There was a statistically significant (p < .001) weak positive correlation (r = .22) between GAD-7 and ACQ-6 scores. In a simple mediation (SMM) model, perceived COVID-19 stress of others was not identified as a significant mediator of the relationship between ACQ-6 and GAD-7 (indirect effect β = 0.014). CONCLUSION Our study of a Canadian cohort demonstrates elevated levels of anxiety overall, amongst both asthma and control groups. While AR status was significantly greater in the asthma group, it was not a significant predictive variable of GAD-7 score. Our data suggests that COVID-19-specific factors appear to have a greater contribution to anxiety than asthma status or control.
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Affiliation(s)
- Sophia Linton
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Kingston General Health Research Institute-Allergy Research Unit, Kingston, ON, Canada
- Kingston Health Science Centre-KGH Site, Kingston, ON, Canada
| | - Kayley Xu
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Lubnaa Hossenbaccus
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Kingston General Health Research Institute-Allergy Research Unit, Kingston, ON, Canada
- Kingston Health Science Centre-KGH Site, Kingston, ON, Canada
| | - Hannah Botting
- Kingston General Health Research Institute-Allergy Research Unit, Kingston, ON, Canada
- Kingston Health Science Centre-KGH Site, Kingston, ON, Canada
| | - Sarah Garvey
- Kingston General Health Research Institute-Allergy Research Unit, Kingston, ON, Canada
- Kingston Health Science Centre-KGH Site, Kingston, ON, Canada
| | - Adam Sunavsky
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Lisa M Steacy
- Kingston General Health Research Institute-Allergy Research Unit, Kingston, ON, Canada
- Kingston Health Science Centre-KGH Site, Kingston, ON, Canada
| | - Dean A Tripp
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Department of Psychology, Queen's University, Kingston, ON, Canada
| | - Anne K Ellis
- Department of Medicine, Queen's University, Kingston, ON, Canada.
- Kingston General Health Research Institute-Allergy Research Unit, Kingston, ON, Canada.
- Kingston Health Science Centre-KGH Site, Kingston, ON, Canada.
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada.
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Cottrill KA, Chandler JD, Kobara S, Stephenson ST, Mohammad AF, Tidwell M, Mason C, Van Dresser M, Patrignani J, Kamaleswaran R, Fitzpatrick AM, Grunwell JR. Metabolomics identifies disturbances in arginine, phenylalanine, and glycine metabolism as differentiating features of exacerbating atopic asthma in children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2023; 2:100115. [PMID: 37609569 PMCID: PMC10443927 DOI: 10.1016/j.jacig.2023.100115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Background Asthma exacerbations are highly prevalent in children, but only a few studies have examined the biologic mechanisms underlying exacerbations in this population. Objective High-resolution metabolomics analyses were performed to understand the differences in metabolites in children with exacerbating asthma who were hospitalized in a pediatric intensive care unit for status asthmaticus. We hypothesized that compared with a similar population of stable outpatients with asthma, children with exacerbating asthma would have differing metabolite abundance patterns with distinct clustering profiles. Methods A total of 98 children aged 6 through 17 years with exacerbating asthma (n = 69) and stable asthma (n = 29) underwent clinical characterization procedures and submitted plasma samples for metabolomic analyses. High-confidence metabolites were retained and utilized for pathway enrichment analyses to identify the most relevant metabolic pathways that discriminated between groups. Results In all, 118 and 131 high-confidence metabolites were identified in positive and negative ionization mode, respectively. A total of 103 unique metabolites differed significantly between children with exacerbating asthma and children with stable asthma. In all, 8 significantly enriched pathways that were largely associated with alterations in arginine, phenylalanine, and glycine metabolism were identified. However, other metabolites and pathways of interest were also identified. Conclusion Metabolomic analyses identified multiple perturbed metabolites and pathways that discriminated children with exacerbating asthma who were hospitalized for status asthmaticus. These results highlight the complex biology of inflammation in children with exacerbating asthma and argue for additional studies of the metabolic determinants of asthma exacerbations in children because many of the identified metabolites of interest may be amenable to targeted interventions.
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Affiliation(s)
| | - Joshua D. Chandler
- Department of Pediatrics, Emory University, Atlanta
- Children’s Healthcare of Atlanta
| | - Seibi Kobara
- Department of Biomedical Informatics, Emory University, Atlanta
| | | | | | | | | | | | | | - Rishikesan Kamaleswaran
- Department of Pediatrics, Emory University, Atlanta
- Department of Biomedical Informatics, Emory University, Atlanta
| | - Anne M. Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta
- Children’s Healthcare of Atlanta
| | - Jocelyn R. Grunwell
- Department of Pediatrics, Emory University, Atlanta
- Children’s Healthcare of Atlanta
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Lizano-Barrantes C, Garin O, Dima AL, Mayoral K, Pont A, Ortiz EM, Caballero-Rabasco MA, Praena-Crespo M, Valdesoiro-Navarrete L, Guerra MT, Bercedo-Sanz A, Hernández G, Maroni C, de Mir I, Carrasco MÁ, Ortega M, Servan A, Castillo JA, Tato E, Ferrer M. Inhaler Technique Questionnaire (InTeQ) in pediatric patients with asthma. World J Pediatr 2023; 19:798-804. [PMID: 36879157 PMCID: PMC10348940 DOI: 10.1007/s12519-023-00695-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 01/29/2023] [Indexed: 03/08/2023]
Affiliation(s)
- Catalina Lizano-Barrantes
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona Biomedical Research Park, Doctor Aiguader, 88, 08003, Barcelona, Spain
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
- Department of Pharmaceutical Care and Clinical Pharmacy, Faculty of Pharmacy, Universidad de Costa Rica, San Jose, Costa Rica
| | - Olatz Garin
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona Biomedical Research Park, Doctor Aiguader, 88, 08003, Barcelona, Spain.
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública CIBERESP, Madrid, Spain.
| | - Alexandra Lelia Dima
- Research and Development Unit, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Karina Mayoral
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona Biomedical Research Park, Doctor Aiguader, 88, 08003, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública CIBERESP, Madrid, Spain
- Department of Pediatrics, Obstetrics and Gynaecology and Preventive Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Angels Pont
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona Biomedical Research Park, Doctor Aiguader, 88, 08003, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública CIBERESP, Madrid, Spain
| | - Eva María Ortiz
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona Biomedical Research Park, Doctor Aiguader, 88, 08003, Barcelona, Spain
- Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - María Araceli Caballero-Rabasco
- Department of Pediatrics, Obstetrics and Gynaecology and Preventive Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Pediatric Allergy and Pulmonology Unit, Pediatric Service, Hospital del Mar, Barcelona, Spain
| | - Manuel Praena-Crespo
- Centro de Salud La Candelaria, Servicio Andaluz de Salud, Seville, Spain
- Grupo de Vías Respiratorias de La Asociación Española de Pediatras de Atención Primaria (AEPAP), Madrid, Spain
- Departamento de Farmacologia, Pediatría y Radiología, Universidad de Sevilla, Seville, Spain
| | - Laura Valdesoiro-Navarrete
- Pediatric Allergy and Pulmonology Unit, Pediatric Service, Hospital Universitari Parc Taulí, Sabadell, Spain
- Institut d'Investigació i Innovació Parc Taulí, Sabadell, Spain
| | - María Teresa Guerra
- Grupo de Vías Respiratorias de La Asociación Española de Pediatras de Atención Primaria (AEPAP), Madrid, Spain
- Centro de Salud Jerez Sur, Servicio Andaluz de Salud, Seville, Spain
| | - Alberto Bercedo-Sanz
- Grupo de Vías Respiratorias de La Asociación Española de Pediatras de Atención Primaria (AEPAP), Madrid, Spain
- Centro de Salud Los Castros, Cantabria, Spain
| | - Gimena Hernández
- Grupo de Vías Respiratorias de La Asociación Española de Pediatras de Atención Primaria (AEPAP), Madrid, Spain
- Centro de Salud La Sagrera, Barcelona, Spain
| | | | - Inés de Mir
- Pediatric Allergy and Pulmonology, and Cystic Fibrosis Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - María Ángeles Carrasco
- Grupo de Vías Respiratorias de La Asociación Española de Pediatras de Atención Primaria (AEPAP), Madrid, Spain
- Consultorio Sevilla la Nueva, Madrid, Spain
| | | | | | - José Antonio Castillo
- Grupo de Vías Respiratorias de La Asociación Española de Pediatras de Atención Primaria (AEPAP), Madrid, Spain
- Hospital Miguel Servet, Zaragoza, Spain
| | - Eva Tato
- Hospital Universitario Araba, Vitoria‑Gasteiz, Spain
| | - Montse Ferrer
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona Biomedical Research Park, Doctor Aiguader, 88, 08003, Barcelona, Spain.
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública CIBERESP, Madrid, Spain.
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Ko FWS, Chan KP, Ng JKC, Ngai JCL, Yip WH, Lo RLP, Chan TO, Hui DSC. 1-Year Prospective Study of the Relationship of Serial Exhaled Nitric Oxide Level and Asthma Control. J Asthma Allergy 2023; 16:725-734. [PMID: 37469451 PMCID: PMC10353557 DOI: 10.2147/jaa.s417117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/30/2023] [Indexed: 07/21/2023] Open
Abstract
Background and Objective Previous studies found that the fractional nitric oxide concentration in exhaled breath (FeNO) levels in healthy Chinese adults was higher than in White adults. More understanding of serial changes of FeNO levels with asthma control in a real-life clinical setting would be important to explore the utility of this biomarker in routine asthma management. This study assessed the FeNO levels of Chinese asthma subjects with different levels of asthma control and the serial changes with respect to the changes in asthma control over 1 year. Methods A 12-month prospective study (subjects recruited between November 2019 and January 2021) with serial measurement of FeNO levels at baseline, 4, 8 and 12 months. Asthma control was assessed by the Global Initiative for Asthma classification, Asthma Control Test (ACT) and Asthma Control Questionnaire (ACQ). Results Altogether, 136 subjects (mean age 51.51±15.09 years, 46[33.8%] male) had successful baseline FeNO measurements. At baseline, the FeNO levels did not show a statistically significant difference for controlled, partly controlled and uncontrolled asthma according to GINA classification, ACT and ACQ. FeNO levels decreased with improving asthma control and stayed at similar levels with unchanged or worsening asthma control for all subjects. For subjects with baseline blood eosinophil levels ≥300 cells/µL(n=59), FeNO levels decreased with improving asthma control, stayed similar without change for asthma control and increased with worsening asthma control. Receiver operating characteristic (ROC) analysis with the highest area under curve (AUC) for changes in FeNO levels for improving asthma control was between ≤ -10 to -25 ppb at various time points in the 12-month study. Conclusion Changes in FeNO levels over time were associated with changes in clinical asthma control, particularly in those with higher blood eosinophil count and are likely more useful than a single time point measurement in managing asthma.
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Affiliation(s)
- Fanny Wai San Ko
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Ka Pang Chan
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Joyce Ka Ching Ng
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Jenny C L Ngai
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Wing Ho Yip
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Rachel Lai Ping Lo
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Tat On Chan
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - David Shu Cheong Hui
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
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50
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Bousema S, Bohnen AM, Bindels PJE, Elshout G. A systematic review of questionnaires measuring asthma control in children in a primary care population. NPJ Prim Care Respir Med 2023; 33:25. [PMID: 37433825 DOI: 10.1038/s41533-023-00344-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 05/15/2023] [Indexed: 07/13/2023] Open
Abstract
Several questionnaires are used to measure asthma control in children. The most appropriate tool for use in primary care is not defined. In this systematic review, we evaluated questionnaires used to measure asthma control in children in primary care and determined their usefulness in asthma management. Searches were performed in the MEDLINE, Embase, Web of Science, Google Scholar and Cochrane databases with end date 24 June 2022. The study population comprised children aged 5-18 years with asthma. Three reviewers independently screened studies and extracted data. The methodological quality of the studies was assessed, using the COSMIN criteria for the measurement properties of health status questionnaires. Studies conducted in primary care were included if a minimum of two questionnaires were compared. Studies in secondary or tertiary care and studies of quality-of-life questionnaires were excluded. Heterogeneity precluded meta-analysis. Five publications were included: four observational studies and one sub-study of a randomized controlled trial. A total of 806 children were included (aged 5-18 years). We evaluated the Asthma Control Test (ACT), childhood Asthma Control Test (c-ACT), Asthma APGAR system, NAEPP criteria and Royal College of Physicians' '3 questions' (RCP3Q). These questionnaires assess different symptoms and domains. The quality of most of the studies was rated 'intermediate' or 'poor'. The majority of the evaluated questionnaires do not show substantial agreement with one another, which makes a comparison challenging. Based on the current review, we suggest that the Asthma APGAR system seems promising as a questionnaire for determining asthma control in children in primary care.
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Affiliation(s)
- Sara Bousema
- Department of General Practice, Erasmus MC, University Medical Centre Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Arthur M Bohnen
- Department of General Practice, Erasmus MC, University Medical Centre Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Patrick J E Bindels
- Department of General Practice, Erasmus MC, University Medical Centre Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Gijs Elshout
- Department of General Practice, Erasmus MC, University Medical Centre Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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