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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: 6] [Impact Index Per Article: 6.0] [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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Use of Asthma Medication During Gestation and Risk of Specific Congenital Anomalies. Immunol Allergy Clin North Am 2023; 43:169-185. [PMID: 36411002 DOI: 10.1016/j.iac.2022.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Poorly controlled asthma can affect neonatal outcomes including congenital anomalies, which can be reduced with appropriate asthma care during pregnancy. Although there is a concern regarding the safety of asthma medication use during pregnancy and congenital anomalies, the risk of uncontrolled asthma outweighs any potential risks of controller and reliever medication use. Patient education before and during pregnancy is critical to ensure good compliance to therapy and reduce the risk of poor asthma control.
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Jiao T, Schnitzer ME, Forget A, Blais L. Identifying asthma patients at high risk of exacerbation in a routine visit: A machine learning model. Respir Med 2022; 198:106866. [DOI: 10.1016/j.rmed.2022.106866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 03/28/2022] [Accepted: 05/04/2022] [Indexed: 11/25/2022]
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Peterka M, Heringova LH, Sukop A, Peterkova R. Anti-asthma Drugs Formoterol and Budesonide (Symbicort) Induce Orofacial Clefts, Gastroschisis and Heart Septum Defects in an In Vivo Model. In Vivo 2021; 35:1451-1460. [PMID: 33910822 DOI: 10.21873/invivo.12397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND We had a case in which three consecutive pregnancies resulted in birth of three children with an orofacial cleft. Their mother suffered from bronchial asthma and was treated using symbicort (corticosteroid budesonide plus bronchodilator formoterol) during her pregnancies. A hypothesis was assessed: these anti-asthmatics can induce an orofacial cleft in experimental model. MATERIALS AND METHODS A single administration of one of five increasing doses (including therapeutically used ones) of Symbicort, budesonide or formoterol was injected into the amnion of a chick embryo on day 4 or 5 of incubation. The teratogenic/lethal effects of the anti-asthmatics were assessed on a total of 600 embryos. RESULTS For budesonide, the teratogenic/lethal effect started at a dose 0.003 μg per embryo, for formoterol at 0.3 μg and for Symbicort 0.03 μg. Orofacial clefts and gastroschisis after exposure were found for all three anti-asthmatics. Heart septum defects occurred after exposure to formoterol. CONCLUSION The present results support those clinical/epidemiological studies pointing out that anti-asthmatics have the potential to induce orofacial clefts, gastroschisis and heart malformations during prenatal development in human.
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Affiliation(s)
- Miroslav Peterka
- Cleft Centre, Clinic of Plastic Surgery, Kralovske Vinohrady University Hospital and Third Faculty of Medicine, Charles University, Prague, Czech Republic; .,Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Lucie Hubickova Heringova
- Institute of Histology and Embryology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Andrej Sukop
- Cleft Centre, Clinic of Plastic Surgery, Kralovske Vinohrady University Hospital and Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Renata Peterkova
- Institute of Histology and Embryology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
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Fernandes M, Caetano A, Pinto M, Medeiros E, Santos L. Diagnosis of DOK7 congenital myasthenic syndrome during pregnancy: A case report and literature review. Clin Neurol Neurosurg 2021; 203:106591. [PMID: 33714798 DOI: 10.1016/j.clineuro.2021.106591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/14/2021] [Accepted: 02/27/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Pregnancy among patients with congenital myasthenic syndrome (CMS) is a rare occurrence. Since most of the patients with CMS reach adulthood, questions regarding clinical outcome with pregnancy arise. CASE REPORT We describe a 38-year-old Portuguese female who presented in the second trimester of pregnancy with proximal fluctuating limb-girdle weakness, hyperlordosis, waddling gait, dysphagia, dysphonia and ptosis, with no ophthalmoparesis. Initial diagnosis of seronegative myasthenia, supported by neurophysiology findings, led to unsuccessful treatment with intravenous immunoglobulin, pyridostigmine, prednisolone and plasmapheresis, and the patient slowly progressed to a severe tetraparesis with facial and bulbar involvement. Genetic testing for CMS identified a novel compound heterozygous mutation (c.1124_1127dupTGCC and c.935_936del) in the DOK7 gene. Subsequent treatment with salbutamol resulted in substantial clinical benefit. CONCLUSIONS This case underlines the importance of considering the diagnosis of CMS in patients with fluctuating weakness during pregnancy. Patients of child-bearing potential diagnosed with CMS, particularly due to DOK7 mutations, should be counseled in advance and closely followed during pregnancy.
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Affiliation(s)
- Marco Fernandes
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Rua da Junqueira 126, 1349-019, Lisbon, Portugal.
| | - André Caetano
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Rua da Junqueira 126, 1349-019, Lisbon, Portugal; CEDOC Chronic Diseases Research Centre, Nova Medical School / Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Miguel Pinto
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Rua da Junqueira 126, 1349-019, Lisbon, Portugal
| | - Elmira Medeiros
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Rua da Junqueira 126, 1349-019, Lisbon, Portugal; CEDOC Chronic Diseases Research Centre, Nova Medical School / Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Luís Santos
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Rua da Junqueira 126, 1349-019, Lisbon, Portugal; CEDOC Chronic Diseases Research Centre, Nova Medical School / Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
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Issa S, Longo C, Forget A, Blais L. Association between the timing of asthma diagnosis and medication use during pregnancy. Pharmacotherapy 2021; 41:342-349. [PMID: 33555035 DOI: 10.1002/phar.2511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 12/14/2020] [Accepted: 01/22/2021] [Indexed: 11/12/2022]
Abstract
STUDY OBJECTIVE To assess whether asthma medication use during pregnancy differs in women newly diagnosed with asthma early in pregnancy (first 19 weeks of pregnancy) compared to those newly diagnosed up to 2 years pre-pregnancy. DESIGN A retrospective population-based cohort study. DATA SOURCE To conduct this study, we used the Quebec Asthma and Pregnancy Database (QAPD) constructed by linking two administrative health databases from the province of Quebec (Canada): the Régie de l'Assurance Maladie du Québec and Maintenance et Exploitation des Données pour l'Étude de la Clientèle Hospitalière databases. PATIENTS A cohort comprising pregnant women newly diagnosed with asthma at any time in the 2 years prior to pregnancy or during the first 19 weeks of pregnancy was selected from the QAPD. MEASUREMENTS AND MAIN RESULTS We assessed the number of filled prescriptions of inhaled corticosteroids (ICS), ICS/long-acting β2 agonists (LABA), and short-acting β2 agonists (SABA), as well as the number of days' supply of oral corticosteroid (OCS) from the 20th week of pregnancy until delivery. Poisson regression was used to compare the rates of asthma medication use in women diagnosed pre-pregnancy versus early in pregnancy. The cohort included 1731 women newly diagnosed with asthma pre-pregnancy and 359 women newly diagnosed with asthma early in pregnancy. Women diagnosed early in pregnancy were more likely to use ICS (adjusted rate ratio: 1.9, 95% confidence interval (CI): 1.6-2.3) and SABA (adjusted rate ratio: 2.0, 95% CI: 1.7-2.4) from the 20th week of pregnancy until delivery than those newly diagnosed pre-pregnancy. No significant differences were observed in the use of ICS/LABA [adjusted rate ratio: 0.9, 95% CI: 0.7-1.3] and OCS [adjusted rate ratio: 0.8, 95% CI: 0.6-1.2]. CONCLUSION The higher use of ICS and SABA observed in women newly diagnosed with asthma early in pregnancy may suggest a more persistent asthma phenotype caused by pregnancy-triggered hormonal changes.
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Affiliation(s)
- Simone Issa
- Faculty of Pharmacy, Université de Montréal, Montréal, Quebec, Canada.,Research Center, Centre Intégré Universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montreal, Quebec, Canada
| | - Cristina Longo
- Faculty of Pharmacy, Université de Montréal, Montréal, Quebec, Canada
| | - Amélie Forget
- Faculty of Pharmacy, Université de Montréal, Montréal, Quebec, Canada.,Research Center, Centre Intégré Universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montreal, Quebec, Canada
| | - Lucie Blais
- Faculty of Pharmacy, Université de Montréal, Montréal, Quebec, Canada.,Research Center, Centre Intégré Universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montreal, Quebec, Canada.,Endowment Pharmaceutical Chair AstraZeneca in Respiratory Health, Montreal, Quebec, Canada
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Davies G, Jordan S, Thayer D, Tucker D, Humphreys I. Medicines prescribed for asthma, discontinuation and perinatal outcomes, including breastfeeding: A population cohort analysis. PLoS One 2020; 15:e0242489. [PMID: 33296383 PMCID: PMC7725302 DOI: 10.1371/journal.pone.0242489] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 11/03/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To explore associations between exposures to medicines prescribed for asthma and their discontinuation in pregnancy and preterm birth [<37 or <32 weeks], SGA [<10th and <3rd centiles], and breastfeeding at 6-8 weeks. METHODS Design. A population-based cohort study. Setting. The Secure Anonymised Information Linkage [SAIL] databank in Wales, linking maternal primary care data with infant outcomes. Population. 107,573, 105,331, and 38,725 infants born 2000-2010 with information on premature birth, SGA and breastfeeding respectively, after exclusions. Exposures. maternal prescriptions for asthma medicines or their discontinuation in pregnancy. Methods. Odds ratios for adverse pregnancy outcomes were calculated for the exposed versus the unexposed population, adjusted for smoking, parity, age and socio-economic status. RESULTS Prescriptions for asthma, whether continued or discontinued during pregnancy, were associated with birth at<32 weeks' gestation, SGA <10th centile, and no breastfeeding (aOR 1.33 [1.10-1.61], 1.10 [1.03-1.18], 0.93 [0.87-1.01]). Discontinuation of asthma medicines in pregnancy was associated with birth at<37 weeks' and <32 weeks' gestation (aOR 1.22 [1.06-1.41], 1.53 [1.11-2.10]). All medicines examined, except ICS and SABA prescribed alone, were associated with SGA <10th centile. CONCLUSIONS Prescription of asthma medicines before or during pregnancy was associated with higher prevalence of adverse perinatal outcomes, particularly if prescriptions were discontinued during pregnancy. Women discontinuing medicines during pregnancy could be identified from prescription records. The impact of targeting close monitoring and breastfeeding support warrants exploration.
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Affiliation(s)
- Gareth Davies
- Faculty of Health and Life Science, Swansea University, Swansea, United Kingdom
| | - Sue Jordan
- Faculty of Health and Life Science, Swansea University, Swansea, United Kingdom
| | - Daniel Thayer
- Faculty of Health and Life Science, Swansea University, Swansea, United Kingdom
| | | | - Ioan Humphreys
- Faculty of Health and Life Science, Swansea University, Swansea, United Kingdom
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Asthma Medication Use and Risk of Birth Defects: National Birth Defects Prevention Study, 1997-2011. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3490-3499.e9. [PMID: 32745701 DOI: 10.1016/j.jaip.2020.07.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/13/2020] [Accepted: 07/16/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Evidence regarding associations between maternal asthma medication use and birth defects is mixed. OBJECTIVE Estimate associations between asthma medciation use and 52 birth defects using National Birth Defects Prevention Study data from 1997 to 2011. METHODS We compared self-reported maternal asthma medication use for 28,481 birth defect cases and 10,894 nonmalformed controls. We calculated adjusted odds ratios (95% CIs) to estimate the risk of birth defects associated with early pregnancy asthma medication use (the month before through the third month of pregnancy), controlling for maternal age, race/ethnicity, body mass index, smoking, folic acid-containing supplement use, and parity. We calculated risks by medication groupings: bronchodilators, anti-inflammatories, and both. RESULTS Overall, 1304 (5%) case and 449 (4%) control women reported early pregnancy asthma medication use. We observed an association between asthma medication use and longitudinal limb deficiency (1.81; 95% CI, 1.27-2.58). Early pregnancy bronchodilator-only use was associated with cleft palate (1.50; 95% CI, 1.11-2.02), cleft lip (1.58; 95% CI, 1.12-2.23), longitudinal limb deficiency (2.35; 95% CI, 1.55-3.54), and truncus arteriosus (2.48; 95% CI, 1.13-5.42). Although early pregnancy anti-inflammatory-only use was not associated with the birth defects studied, use of both medications was associated with biliary atresia (3.60; 95% CI, 1.55-8.35) and pulmonary atresia (2.50; 95% CI, 1.09-5.78). CONCLUSIONS Consistent with previous National Birth Defects Prevention Study analyses, asthma medication use was not associated with most birth defects examined, but we observed modest risks for bronchodilator use and several birth defects. Our findings support maintaining adequate asthma treatment during pregnancy, because early pregnancy asthma exacerbations have been associated with adverse birth outcomes, including birth defects.
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Asthma in Pregnancy: Pathophysiology, Diagnosis, Whole-Course Management, and Medication Safety. Can Respir J 2020; 2020:9046842. [PMID: 32184907 PMCID: PMC7060439 DOI: 10.1155/2020/9046842] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 01/18/2020] [Indexed: 12/16/2022] Open
Abstract
Asthma in pregnancy is a health issue of great concern. Physiological changes and drug compliance during pregnancy can affect asthma control in varying degrees, and the control level of asthma and the side effects of asthma medications are closely related to the adverse perinatal outcomes of mother and fetus. This article provides an update on the available literature regarding the alleviating or aggravating mechanism of asthma in pregnancy, diagnosis, disease assessment, and systematic management, to provide a new guidance for physician, obstetric joint doctor, and health care practitioner.
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Yland JJ, Bateman BT, Huybrechts KF, Brill G, Schatz MX, Wurst KE, Hernández-Díaz S. Perinatal Outcomes Associated with Maternal Asthma and Its Severity and Control During Pregnancy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1928-1937.e3. [PMID: 31981730 DOI: 10.1016/j.jaip.2020.01.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/10/2020] [Accepted: 01/10/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Estimates of the effects of maternal asthma on pregnancy outcomes are inconsistent across studies, possibly because of differences in exposure definition. OBJECTIVE To evaluate the risk of adverse perinatal outcomes associated with maternal asthma diagnosis, severity, and control in a large, nationally representative cohort. METHODS This study was conducted within the IBM Health MarketScan Commercial Claims and Encounters Database (2011-2015) and the Medicaid Analytic eXtract database (2000-2014). Asthma was identified by diagnosis and treatment codes, severity was based on medications dispensed, and control was based on short-acting β-agonist dispensations and exacerbations. We estimated the relative risks (RRs) of stillbirth, spontaneous abortion, preterm birth, small for gestational age (SGA), neonatal intensive care unit (NICU) admission, and congenital malformations, comparing pregnancies with differing asthma disease status. RESULTS We identified 29,882 pregnancies complicated by asthma in the MarketScan database and 160,638 in the Medicaid Analytic eXtract database. We observed no consistent associations between asthma diagnosis, severity, or control, and stillbirth, abortions, or malformations. However, we observed increased risks of prematurity, SGA, and NICU admission among women with asthma compared with those without asthma. Compared with women with well-controlled asthma, women with poor control late in pregnancy had an increased risk of preterm birth (relative risk, 1.39; 95% CI, 1.32-1.46) and NICU admission (relative risk, 1.26; 95% CI, 1.17-1.35). More severe asthma was associated with SGA (relative risk, 1.18; 95% CI, 1.07-1.30). CONCLUSIONS We did not observe an increased risk of pregnancy losses or malformations among women with asthma. However, we found an association between asthma severity and SGA, and between exacerbations late in pregnancy and preterm delivery and NICU admission.
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Affiliation(s)
- Jennifer J Yland
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Mass.
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass; Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Gregory Brill
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Michael X Schatz
- Department of Allergy, Kaiser Permanente Medical Center, San Diego, Calif
| | - Keele E Wurst
- Department of Epidemiology and Real-World Evidence, GSK, Collegeville, Pa
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Mass
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Cohen JM, Bateman BT, Huybrechts KF, Mogun H, Yland J, Schatz M, Wurst KE, Hernandez-Diaz S. Poorly Controlled Asthma During Pregnancy Remains Common in the United States. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2672-2680.e10. [PMID: 31257187 DOI: 10.1016/j.jaip.2019.05.043] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/15/2019] [Accepted: 05/15/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Asthma is among the most common preexisting medical conditions in pregnancy. Uncontrolled asthma may increase the risk of adverse pregnancy outcomes. OBJECTIVES To describe the prevalence, severity, and control of asthma during pregnancy in the United States. METHODS We identified 2 cohorts of pregnancies ending in a live birth within 2 large US health care claims databases: the Truven Health MarketScan Commercial Claims and Encounters Database (MarketScan, private insurance) for the period 2011 to 2015 and the nationwide Medicaid Analytic eXtract (MAX, public insurance) for the period 2000 to 2013. We defined asthma prevalence, severity, and control on the basis of International Classification of Diseases, 9th Revision diagnoses and asthma-related treatments. Severe asthma was defined as dispensing of 1 or more medium/high-dose inhaled corticosteroid plus additional therapy within the 12 months preceding delivery. Poor control was defined as having at least 1 of the following: 1 or more exacerbation (asthma-related hospitalization or emergency room visit, or a course of oral corticosteroids) or 5 or more filled prescriptions for short-acting β-agonists between the last menstrual period and delivery. RESULTS Among 604,420 pregnant women in MarketScan and 2,071,359 in MAX, 20,104 (3.3%) and 120,745 (5.8%) had asthma, respectively. Among pregnant women with asthma, 19.0% and 18.8% had severe asthma and 16.5% and 28.0% had poorly controlled asthma in MarketScan and MAX, respectively. Many women with poorly controlled asthma during pregnancy were not dispensed a long-term controller (38.4% in MarketScan and 43.3% in MAX). Within both cohorts, women with poor control were more often smokers and obese, had more comorbidities, and used more concomitant nonasthma medications. CONCLUSIONS Poorly controlled asthma is more frequent among publicly versus privately insured pregnancies in the United States. Dispensing of long-term controller medications during pregnancy remains low, even for symptomatic patients.
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Affiliation(s)
- Jacqueline M Cohen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Mass
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass; Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Jennifer Yland
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Mass
| | - Michael Schatz
- Department of Allergy, Kaiser Permanente Medical Center, San Diego, Calif
| | - Keele E Wurst
- Department of Epidemiology and Real-World Evidence, GSK, Collegeville, Pa
| | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Mass.
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Frank E, Ishau S, Maier A, Reutman S, Reichard JF. An occupational exposure limit (OEL) approach to protect home healthcare workers exposed to common nebulized drugs. Regul Toxicol Pharmacol 2019; 106:251-261. [PMID: 31047944 DOI: 10.1016/j.yrtph.2019.04.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 04/22/2019] [Accepted: 04/25/2019] [Indexed: 11/25/2022]
Abstract
Home healthcare is a growing area of employment. Assessment of occupational health risks to home health care workers (HHCWs) is important because in many cases the unique characteristics of the home environment do not facilitate the level of exposure control afforded to caregivers in hospitals and other fixed patient care sites. This assessment is focused on health risks to HHCWs from exposure to pharmaceutical drugs used to treat asthma and other respiratory diseases, which are commonly administered to patients in aerosolized form via nebulizers. We developed risk-based exposure limits for workers in the form of occupational exposure limits (OEL) values for exposure to nebulized forms of the three most common drugs administered by this method: albuterol, ipratropium, and budesonide. The derived OEL for albuterol was 2 μg/day, for ipratropium was 30 μg/day, and for budesonide was 11 μg/day. These OELs were derived based on human effect data and adjusted for pharmacokinetic variability and areas of uncertainty relevant to the underlying data (human and non-human) available for each drug. The resulting OEL values provide an input to the occupational risk assessment process to allow for comparisons to HHCW exposure that will guide risk management and exposure control decisions.
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Affiliation(s)
- Evan Frank
- University of Cincinnati, College of Medicine, Department of Environmental Health, USA
| | - Simileoluwa Ishau
- University of Cincinnati, College of Medicine, Department of Environmental Health, USA
| | - Andrew Maier
- University of Cincinnati, College of Medicine, Department of Environmental Health, and Cardno ChemRisk, USA
| | | | - John F Reichard
- University of Cincinnati, College of Medicine, Department of Environmental Health, USA.
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van de Putte R, de Blaauw I, Boenink R, Reijers MHE, Broens PMA, Sloots CEJ, van Heijst AFJ, van Gelder MMHJ, Roeleveld N, van Rooij IALM. Uncontrolled maternal chronic respiratory diseases in pregnancy: A new potential risk factor suggested to be associated with anorectal malformations in offspring. Birth Defects Res 2018; 111:62-69. [PMID: 30569656 PMCID: PMC7380291 DOI: 10.1002/bdr2.1429] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 11/01/2018] [Accepted: 11/03/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chronic respiratory diseases and use of antiasthmatic medication during pregnancy may both play a role in the etiology of congenital anorectal malformations (ARM). However, it is unclear, whether the medication use or the underlying condition would be responsible. Therefore, our aim was to unravel the role of maternal chronic respiratory diseases from that of antiasthmatic medication in the etiology of ARM. METHODS We obtained 412 ARM patients and 2,137 population-based controls from the Dutch AGORA data- and biobank. We used maternal questionnaires and follow-up telephone interviews to obtain information on chronic respiratory diseases, antiasthmatic medication use, and potential confounders. Multivariable logistic regression analyses were performed to estimate odds ratios (ORs) with 95% confidence intervals (95% CI). RESULTS We observed higher risk estimates among women with chronic respiratory diseases with and without medication use (1.4 [0.8-2.7] and 2.0 [0.8-5.0]), both in comparison to women without a chronic respiratory disease and without medication use. Furthermore, increased ORs of ARM were found for women using rescue medication (2.4 [0.8-7.3]) or a combination of maintenance and rescue medication (2.5 [0.9-6.7]). In addition, increased risk estimates were observed for women having nonallergic triggers (2.5 [1.0-6.3]) or experiencing exacerbations during the periconceptional period (3.5 [1.4-8.6]). CONCLUSIONS Although the 95% CIs of most associations include the null value, the risk estimates all point towards an association between uncontrolled chronic respiratory disease, instead of antiasthmatic medication use, with ARM in offspring. Further in-depth studies towards mechanisms of this newly identified risk factor are warranted.
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Affiliation(s)
- Romy van de Putte
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud university medical center (Radboudumc), Nijmegen, The Netherlands
| | - Ivo de Blaauw
- Department of Surgery-Paediatric surgery, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Rianne Boenink
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud university medical center (Radboudumc), Nijmegen, The Netherlands
| | | | - Paul M A Broens
- Department of Surgery, Division of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Cornelius E J Sloots
- Department of Pediatric Surgery, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Arno F J van Heijst
- Department of Pediatrics-Neonatology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Marleen M H J van Gelder
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud university medical center (Radboudumc), Nijmegen, The Netherlands.,REshape Innovation Center, Radboudumc, Nijmegen, The Netherlands
| | - Nel Roeleveld
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud university medical center (Radboudumc), Nijmegen, The Netherlands
| | - Iris A L M van Rooij
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud university medical center (Radboudumc), Nijmegen, The Netherlands.,Department of Surgery-Paediatric surgery, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
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14
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Bolz M, Körber S, Reimer T, Buchmann J, Schober HC, Briese V. The Treatment of Illnesses Arising in Pregnancy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:616-626. [PMID: 28974300 DOI: 10.3238/arztebl.2017.0616] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 01/24/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND The treatment of pregnant women who have illnesses unrelated to pregnancy can cause uncertainty among physicians. METHODS We searched the PubMed database and specialty guidelines from Germany and abroad (the guidelines of the German Society for Gynecology and Obstetrics, the American Congress of Obstetri cians and Gynecologists, and the Royal College of Obstetricians and Gynaecologists) over the period 2007-2016 for information on standards for the diagnosis and treatment of five illnesses that can arise in pregnancy: bronchial asthma, migraine, hypothyroidism, hyperthyroidism, and varicose veins. RESULTS Any diagnostic tests that are carried out in pregnant women should be simple and goal-directed. The choice of drugs that can be used is limited. For many drugs, no embryotoxic or teratogenic effect is suspected, but the level of evidence is low. CONCLUSION When illnesses unrelated to pregnancy arise in pregnant women, attention must be paid to potential diver gences from the typical disease course and to pos sible drug side effects on the fetus in order to prevent serious complications for both mother and child.
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15
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Lefebvre G, Samoilenko M. On the use of the outcome variable "small for gestational age" when gestational age is a potential mediator: a maternal asthma perspective. BMC Med Res Methodol 2017; 17:165. [PMID: 29228913 PMCID: PMC5725795 DOI: 10.1186/s12874-017-0444-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 11/27/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The variable "small for gestational age," frequently defined as birth weight below the 10th percentile in a gestational age and sex-normalized population, is nowadays generally perceived as a more adequate measure than birth weight or low birth weight (birth weight < 2500 g) to capture fetal growth. However, the use of small for gestational age rather than birth weight or low birth weight as an outcome (dependent) variable may have important impacts on the interpretation of analyses aimed at estimating the causal effect of an exposure of interest on infants. We hypothesized potential differences in both types of effects estimated (direct or total) and in ability to control for confounding bias. METHODS We first examined the use of outcome variables birth weight and small for gestational age to get insights on modeling practices within the field of maternal asthma. Using directed acyclic graph simulations where gestational age was a potential mediator, we then compared estimated exposure effects in regression models for birth weight, low birth weight, and small for gestational age. Graphs with and without confounding were considered. RESULTS Our simulations showed that the variable small for gestational age captures the direct effect of exposure on birth weight, but not the indirect effect of exposure on birth weight through gestational age. Interestingly, exposure effect estimates from small for gestational age models were found unbiased whenever exposure effect estimates from birth weight models were affected by collider bias due to conditioning on gestational age in the models. CONCLUSIONS The sole consideration of the outcome small for gestational age in a study may lead to suboptimal understanding and quantification of the underlying effect of an exposure on birth weight-related measures. Instead, our results suggest that both outcome variables (low) birth weight and small for gestational age should minimally be considered in studies investigating perinatal outcomes.
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Affiliation(s)
- Geneviève Lefebvre
- Department of Mathematics, Université du Québec à Montréal, C.P. 8888, Succursale Centre-ville, Montréal, Québec, H3C 3P8, Canada. .,Faculty of Pharmacy, Université de Montréal, Montréal, Canada.
| | - Mariia Samoilenko
- Department of Mathematics, Université du Québec à Montréal, C.P. 8888, Succursale Centre-ville, Montréal, Québec, H3C 3P8, Canada
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16
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Martinez-Moragón E, Romero-Falcón A, García-Rivero JL. Algorithm for the management of asthma in pregnant women: a protocol to optimize processes in healthcare. Expert Rev Respir Med 2017; 11:1003-1012. [PMID: 29016232 DOI: 10.1080/17476348.2017.1391094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Asthma is the most common chronic disease in pregnant women. Its evolution during pregnancy could improve, stay the same or worsen, especially in cases where there is a loss of clinical control. This can lead to maternal and fetal hypoxia with serious adverse perinatal outcomes. Areas covered: This article reviews physiological modifications in pregnancy, effects of pregnancy on asthma, and possible consequences on fetus development. Furthermore, it reviews evidence on assessment and both pharmacological and non-pharmacological management of asthma in pregnant and breastfeeding women as well as in acute exacerbations. Electronic databases, such as PUBMED, were searched for terms pregnan* or perinat* or obstet* and breastfeeding or asthma or wheeze, as well as a book published by the present authors. Expert commentary: A patient-centered multidisciplinary approach, where the respiratory specialists have a key role in assessing and achieving control, as well as the education interventions for self-monitoring and adherence are at least as important as adequate pharmacological treatment.
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Affiliation(s)
| | - Auxiliadora Romero-Falcón
- b Unidad de Asma. Unidad Médico-Quirúrgica de Enfermedades Respiratorias , Hospital Universitario Virgen del Rocío , Sevilla , Spain
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17
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Pazheri F, Schroer BC. Agonizing over Beta 2 Agonists and Autism. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2017; 5:533-534. [PMID: 36444003 DOI: 10.1016/j.jaip.2016.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 09/21/2016] [Accepted: 09/23/2016] [Indexed: 06/16/2023]
Affiliation(s)
- Fouseena Pazheri
- Cleveland Clinic Foundation, Allergy and Clinical Immunology, Respiratory Institute, Cleveland, Ohio.
| | - Brian C Schroer
- Cleveland Clinic Foundation, Allergy and Clinical Immunology, Respiratory Institute, Cleveland, Ohio
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18
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Blackburn HK, Allington DR, Procacci KA, Rivey MP. Asthma in pregnancy. World J Pharmacol 2014; 3:56-71. [DOI: 10.5497/wjp.v3.i4.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 08/01/2014] [Accepted: 09/17/2014] [Indexed: 02/06/2023] Open
Abstract
Asthma affects approximately 8% of women during pregnancy. Pregnancy results in a variable course for asthma control, likely contributed to by physiological changes affecting the respiratory, immune, and hormonal systems. While asthma during pregnancy has been associated with an increased risk of maternal and fetal complications including malformations, available data also suggest that active asthma management and monitoring can decrease the risk of adverse outcomes. The diagnosis, disease classification, and goals for asthma management in the pregnant woman are the same as for nonpregnant patients. However, evidence shows that pregnant asthmatics are more likely to be undertreated, resulting in asthma exacerbations occurring in approximately one third and hospitalization in one tenth of patients. Pharmacotherapeutic management of asthma exacerbations in pregnant patients follows standard treatment guidelines. In contrast, the principles of asthma maintenance therapy are slightly modified in the pregnant patient. Patients and practitioners may avoid use of asthma medications due to concern for a risk of fetal complications and malformations. A variable amount of information is available regarding the risk of a given asthma medication to cause adverse fetal outcomes, and it is preferable to use an inhaled product. Nevertheless, based on available data, the majority of asthma medications are regarded as safe for use during pregnancy. And, any increased risk to either the mother or fetus from medication use appears to be small compared to that associated with poor asthma control.
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Cano I, Lluch-Ariet M, Gomez-Cabrero D, Maier D, Kalko S, Cascante M, Tegnér J, Miralles F, Herrera D, Roca J. Biomedical research in a Digital Health Framework. J Transl Med 2014; 12 Suppl 2:S10. [PMID: 25472554 PMCID: PMC4255881 DOI: 10.1186/1479-5876-12-s2-s10] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This article describes a Digital Health Framework (DHF), benefitting from the lessons learnt during the three-year life span of the FP7 Synergy-COPD project. The DHF aims to embrace the emerging requirements--data and tools--of applying systems medicine into healthcare with a three-tier strategy articulating formal healthcare, informal care and biomedical research. Accordingly, it has been constructed based on three key building blocks, namely, novel integrated care services with the support of information and communication technologies, a personal health folder (PHF) and a biomedical research environment (DHF-research). Details on the functional requirements and necessary components of the DHF-research are extensively presented. Finally, the specifics of the building blocks strategy for deployment of the DHF, as well as the steps toward adoption are analyzed. The proposed architectural solutions and implementation steps constitute a pivotal strategy to foster and enable 4P medicine (Predictive, Preventive, Personalized and Participatory) in practice and should provide a head start to any community and institution currently considering to implement a biomedical research platform.
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Affiliation(s)
- Isaac Cano
- IDIBAPS-Hospital Clínic, CIBERES, Universitat de Barcelona, 08036, Barcelona, Catalunya, Spain
| | - Magí Lluch-Ariet
- Department of eHealth, Barcelona Digital, Roc Boronat 117, 08017 Barcelona, Catalunya, Spain
| | - David Gomez-Cabrero
- Unit of Computational Medicine, Department of Medicine, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Dieter Maier
- Biomax Informatics AG, Robert-Koch-Str. 2, Planegg, Germany
| | - Susana Kalko
- IDIBAPS-Hospital Clínic, CIBERES, Universitat de Barcelona, 08036, Barcelona, Catalunya, Spain
| | - Marta Cascante
- IDIBAPS-Hospital Clínic, CIBERES, Universitat de Barcelona, 08036, Barcelona, Catalunya, Spain
- Departament de Bioquimica i Biologia Molecular i IBUB, Facultat de Biologia, Universitat de Barcelona, 08028 Barcelona, Spain
| | - Jesper Tegnér
- Unit of Computational Medicine, Department of Medicine, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Felip Miralles
- Department of eHealth, Barcelona Digital, Roc Boronat 117, 08017 Barcelona, Catalunya, Spain
| | - Diego Herrera
- Departament de Bioquimica i Biologia Molecular i IBUB, Facultat de Biologia, Universitat de Barcelona, 08028 Barcelona, Spain
- Almirall R&D, 08980 Sant Feliu de Llobregat, Barcelona, Spain
| | - Josep Roca
- IDIBAPS-Hospital Clínic, CIBERES, Universitat de Barcelona, 08036, Barcelona, Catalunya, Spain
- Centro de Investigacíon Biomédica en Red de Enfermedades Respiratorias (CIBERES), Bunyola, Balearic Islands
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20
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Steinberg JA. Perception versus reality: the saga of inhaled asthma controller medication and fetal risk. J Allergy Clin Immunol 2014; 135:131-2. [PMID: 25445824 DOI: 10.1016/j.jaci.2014.09.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 09/30/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Joshua A Steinberg
- Division of Allergy/Immunology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis.
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21
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Eltonsy S, Forget A, Beauchesne MF, Blais L. Risk of congenital malformations for asthmatic pregnant women using a long-acting β₂-agonist and inhaled corticosteroid combination versus higher-dose inhaled corticosteroid monotherapy. J Allergy Clin Immunol 2014; 135:123-30. [PMID: 25226849 DOI: 10.1016/j.jaci.2014.07.051] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 06/27/2014] [Accepted: 07/30/2014] [Indexed: 01/24/2023]
Abstract
BACKGROUND Current recommendations for managing persistent asthma during pregnancy when low-dose inhaled corticosteroids (ICSs) are insufficient include adding a long-acting β₂-agonist (LABA) or increasing the ICS dose. However, there are no data to help clinicians evaluate the safest regimen during pregnancy. OBJECTIVE We sought to compare the risk of major congenital malformations in asthmatic women exposed to a LABA plus ICS combination and those exposed to ICS monotherapy at higher doses during the first trimester. METHODS A cohort of asthmatic pregnant women exposed to ICSs during the first trimester who delivered between January 1990 and March 2009 was established. The primary outcome was major malformation recorded at birth or during the first year of life. Two subcohorts were established as follows: (1) users of a LABA plus low-dose ICS combination or users of a medium-dose ICS and (2) users of a LABA plus medium-dose ICS combination or users of a high-dose ICS. Generalized estimating equations were used to compare the risk of major malformations between the groups. RESULTS In one subcohort there were 643 women who used a LABA plus low-dose ICS and 305 who used a medium-dose ICS; the other subcohort included 198 users of a LABA plus medium-dose ICS and 156 users of a high-dose ICS. The prevalence of major malformations was 6.9% and 7.2%, respectively. The adjusted odds ratio for major malformations was 1.1 (95% CI, 0.6-1.9) when a LABA plus low-dose ICS was used compared with a medium-dose ICS and 1.2 (95% CI, 0.5-2.7) when a LABA plus medium-dose ICS was used compared with a high-dose ICS. CONCLUSION The risk of major malformations was similar with a LABA plus ICS combination and ICS monotherapy at higher doses, suggesting that both therapeutic options can be considered during pregnancy.
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Affiliation(s)
- Sherif Eltonsy
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada; Hopital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Amelie Forget
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada; Hopital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Marie-France Beauchesne
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada; Département de Pharmacie, Centre Hospitalier Universitaire de Sherbrookes, Sherbrooke, Quebec, Canada
| | - Lucie Blais
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada; Hopital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada.
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