Implementation gaps for asthma prevention and control

The lived experiences of mother's caring for children with uncontrolled asthma: A qualitative study

Introduction

Childhood-onset asthma is a chronic respiratory disease that profoundly impacts patients, their families, and healthcare systems. This study explores the lived experiences, challenges, and perceptions of mothers in managing asthma, controlling symptoms, and maintaining the quality of life for their children with asthma in Palestine.

Methods

A qualitative descriptive design through semi-structured interviews was used in this study. Purposive sampling was used to identify mothers who have children with severe uncontrolled asthma in the four public hospitals with pediatric units in the West Bank, Palestine. Mothers of children with scored below 15 on the asthma control test were included in the study. The data were analyzed using an analytical framework following a thematic analysis through the NVivo 11.

Results

A total of 20 mothers participated in interviews wherein they delineated the most important challenges negatively affecting asthma management from mothers' perspectives. These challenges encompassed frequent emergency room visits, improper medication administration practices, and limitations in physical activity. The mothers expressed concerns regarding asthma control, including anxieties concerning the chronicity of the illness, adverse effects of medications, and susceptibility to weather fluctuations. The main themes that emerged from the data included reduced quality of life for the child, parental responsibility for monitoring triggers, symptoms, and medications, challenges in asthma management, apprehensions regarding asthma control, and strategies for enhancing asthma management.

Conclusion

This study emphasizes the pressing need for targeted interventions to address asthma management, environmental triggers, and psychosocial disruptions related to asthma in children with asthma to enhance the quality of life and asthma control. This study highlights the importance of developing strategies that provide mothers with the appropriate information and tools to navigate the complexities of caring for a child with asthma.

Allergic and hypersensitivity condition in the International Patients' Summary (IPS) standard: The need of updates through the International Classification of Diseases (ICD)-11

In 2010, the United States Human and Health Services (US HHS) and the European Union's (EU) Directorate General for Communications Networks, Content and Technology signed a memorandum of understanding to stimulate cooperation surrounding health-related information communications technology. The key project that emerged from this agreement is the International Patient Summary (IPS), intended to provide succinct clinically relevant patient summaries, which are generalizable and condition-independent, that can be readily used by all clinicians for the care of patients. Although allergies are included in the main information required by the IPS library and framework, it is misrepresented which leads to underdiagnosis or misdiagnosis of patients suffering from allergic and hypersensitivity conditions (A/H). The French and Montpellier World Health Organization (WHO) Collaborating Centres have provided arguments for supporting representation of A/H in the IPS. These are based on the relevance of the new classification of A/H in the WHO International Classification of Diseases 11th version (ICD-11), and the need for alignment of eHealth tools with harmonized health information. We first present the A/H in the IPS initiative with the mission of producing an international information system that can be used globally in electronic health records to standardize clinical diagnoses and facilitate communication between clinicians caring for patients with A/H diseases. It is believed this initiative will provide a strong voice for the allergy community and an effective process for improving the quality of health data that will optimize medical care for our patients worldwide.

Symptom control and health-related quality of life in allergic rhinitis with and without comorbid asthma: A multicentre European study

BACKGROUND

Allergic rhinitis (AR) is a major non-communicable disease that affects the health-related quality of life (HRQoL) of patients. However, data on HRQoL and symptom control in AR patients with comorbid asthma (AR + asthma) are lacking.

METHODS

In this multicentre, cross-sectional study, patients with AR were screened and administered questionnaires of demographic characteristics and health conditions (symptoms/diagnosis of AR and asthma, disease severity level, and allergic conditions). HRQoL was assessed using a modified version of the RHINASTHMA questionnaire (30, 'not at all bothered' - 150 'very much bothered') and symptom control was evaluated by a modified version of the Control of Allergic Rhinitis/Asthma Test (CARAT) (0, 'no control' - 30, 'very high control').

RESULTS

Out of 643 patients with AR, 500 (78%) had asthma as a comorbidity, and 54% had moderate-severe intermittent AR, followed by moderate-severe persistent AR (34%). Compared to the patients with AR alone, patients with AR + asthma had significantly higher RHINASTHMA (e.g., median RHINASTHMA-total score 48.5 vs. 84, respectively) and a significantly lower CARAT score (median CARAT-total score 23 vs. 16.5, respectively). Upon stratifying asthma based on severity, AR patients with severe persistent asthma had worse HRQoL and control than those with mild persistent asthma. The association was significantly higher among non-obese participants compared to obese ones, with RHINASTHMA-upper symptoms score but not with CARAT.

CONCLUSIONS

Our observation of poorer HRQoL and symptoms control in AR patients with comorbid asthma supports the importance of a comprehensive approach for the management of AR in case of a comorbid allergic condition.

Global burden of asthma associated with high body mass index from 1990 to 2019

BACKGROUND

High body mass index (BMI) plays a key role in the progression of asthma and asthma related to high BMI resulted in a high burden of disease globally.

OBJECTIVE

This study aimed to explore the geographical and temporal trends in the global burden of asthma associated with high BMI from 1990 to 2019.

METHODS

This is a retrospective analysis with data based on the Global Burden of Disease Study 2019 database. The deaths, disability-adjusted life-years (DALYs), age-standardized mortality rate (ASMR) and age-standardized DALY rate (ASDR) were estimated according to sex, age and sociodemographic indexes (SDI) levels. Estimated annual percentage change (EAPC) was used to evaluate the variation trends of ASMR and ASDR from 1990 to 2019.

RESULTS

In 2019, the number of global asthma deaths and DALYs related to high BMI increased by 69.69% and 63.91% respectively compared with 1990, among which more deaths and DALYs occurred in females. The corresponding ASMR and ASDR showed a slightly decreasing tendency globally. South Asia accounted for the highest number of deaths and DALYs, with India ranked first worldwide in 2019. The number of deaths and DALYs mainly appeared in individuals 60-79 years old and 55-69 years old respectively from 1990 to 2019. The heaviest burden existed in the low-middle SDI region.

CONCLUSION

The global asthma burden associated with obesity increased in absolute value but the standardized burden decreased slightly. Large variations existed in the high BMI-related asthma burdens among sexes, ages and regions.

Levels of indoor particulate matter and association with asthma in children in Benin City, Nigeria

The relationship between indoor particulate matter and asthma in children was assessed in this study. Forty-five (45) locations were randomly selected across the five local government areas in Benin City, Edo State, for air quality assessment. Indoor and outdoor particulates (PM_1.0, PM_2.5, and PM₁₀) were monitored monthly using a handheld BLATN particulate sampler (Br-Smart-126S series). Reported clinical cases of asthma in children from 2008 to 2017 were collected from two major hospitals in the metropolis. The data obtained were analysed with SPSS for Windows version 21.0. The average concentrations of indoor and ambient PM ranged between 10.7-26.2 and 19.0-49.4 µg/m³ (PM_1.0), 27.4-59.6 and 45.6-93.0 µg/m³ (PM_2.5), and 33.5-67.9 and 60.9-106.1 µg/m³ (PM₁₀) in the wet and dry seasons. PM_2.5 and PM₁₀ concentrations were observed above the WHO standards. Indoor particulate concentration was significantly (p = 0.001-0.012) higher in the dry season across the locations. Outdoor PM correlated positively (R = 0.568-0.855, p < 0.05; R² = 0.322-0.724, p < 0.001) with their corresponding indoor PM concentration. The hazard ratio (HR) values of PM_2.5 and PM₁₀ exceeded 1 in all the sampling locations during the dry season, while the mean total hazard ratio (THR) of both PM metrics was considerably higher during the dry season than in the wet season. Indoor PM concentrations showed a significant positive correlation with reported cases of asthma (R = 0.498-0.542, p < 0.001) and accounted for 40.6% of the asthma cases during the dry season. The study showed that children in the selected households are at risk of increased asthma exacerbation due to exposure to particulate matter pollution.

Pollen allergy: Developing multi-sectorial strategies for its prevention and control in lower and middle-income countries

Pollen allergy is considered a major public health problem that causes morbidity and subsequently affects a patient's quality of life. Pollen due to their large size cannot enter the thoracic regions of the respiratory tract but can affect the nasopharyngeal mucous membrane. At the same time, the submicronic-pollen particles can act as respirable particles reaching deeper into the upper airways leading to exacerbation of asthma, chronic obstructive pulmonary disease (COPD) and other allergic reactions. Based on the existing literature, expanding evidence shows that climate change and air pollutants could affect the pollen number, morphology, season, allergen content, and distribution pattern. Hence, this will influence the prevalence and occurrence of allergies linked to pollen exposure. Being a part of biogenic pollutants, pollen allergens are not expected to diminish in the foreseeable future. Therefore, it is imperative that steps need to be strengthened to improve and optimize preventive/adaptive strategies. This paper aims to review the major causes of widespread allergy, identify the major gaps, and suggest key preventive/adaptive measures to address the onset and exacerbation of pollen-related allergic diseases with a major focus on lower and middle-income countries. The study also discusses how-to implement the prevention and control measures at the individual, health care communities and organizations, Local Governments, National/International Governments levels to decrease the risk of illnesses associated with pollen allergy.

Susceptibility to rhinovirus-induced early wheezing as a risk factor for subsequent asthma development

Abstract:

Rhinovirus is one of the two most common viral agents that cause bronchiolitis in young children. During the first 12 months, it is second to the respiratory syncytial virus, but after 12 months, it begins dominating the statistics. Wheezing and dry cough are typical clinical symptoms indicative of rhinovirus-induced bronchiolitis, although overlap of symptoms with other virus infections is common. Several studies have shown that atopic predisposition and reduced interferon responses increase susceptibility to rhinovirus-induced wheezing. More recent studies have found that certain genetic variations at strong asthma loci also increase susceptibility. Rhinovirus-induced wheezing in the early years of life is known to increase the risk of subsequent asthma development and may be associated with airway remodeling. This risk is increased by aeroallergen sensitization. Currently, there are no clinically approved preventive treatments for asthma. However, studies show promising results indicating that children with rhinovirus-affected first-time wheezing respond to bronchodilators in terms of less short-term symptoms and that controlling airway inflammatory responses with anti-inflammatory medication may markedly decrease asthma development. Also, enhancing resistance to respiratory viruses has been a topic of discussion. Primary and secondary prevention strategies are being developed with the aim of decreasing the incidence of asthma. Here, we review the current knowledge on rhinovirus-induced early wheezing as a risk factor for subsequent asthma development and related asthma-prevention strategies.

Tectorigenin regulates migration, invasion, and apoptosis in dexamethasone-induced human airway epithelial cells through up-regulating miR-222-3p

Glucocorticoids (GCs) can effectively control airway inflammation, but can also cause airway epithelial injury. Tectorigenin, a type of isoflavone isolated from various medicinal plants, has hypolipidemic activity, hepatoprotective, and antioxidant effects. We aimed to investigate whether Tectorigenin can repair GCs-induced airway epithelial injury. Airway epithelial cell line (9HTE cells) were treated with dexamethasone (Dex), Tectorigenin, or further transfected, then cell viability, migration, and invasion were examined by Cell Counting Kit (CCK-8), wound healing, and Transwell assays. The expressions of potential miRNAs related to the effect of Tectorigenin were detected by quantitative polymerase chain reaction (qPCR). Expressions of poptosis-related proteins Bcl-2-associated protein-X (Bax), B-cell lymphoma-2 (Bcl-2), Cleaved Caspase-3, and related to Mitorgen-activated protein kinase (MAPK) signaling pathway serine/threonine kinase (Raf1), extracellular signal-regulated kinase kinase 1/2 (MEK1/2), and extracellular signal-regulated kinase 1/2 (ERK1/2) were detected by Western blot. Dex inhibited the cell viability, migration and invasion by promoting Bax and Cleaved Caspase-3 expressions (p <.001) and by inhibiting the expressions of Bcl-2 and miR-222-3p (p <.001). Then, 10 μmol/L Tectorigenin itself did not affect cell viability but could inhibit the effect of Dex on cell viability, migration, and invasion. Tectorigenin up-regulated the expressions of miR-222-3p, Bcl-2, p-Raf1, p-MEK1/2, and p-ERK1/2 (p <.01), but down-regulated the expressions of Bax and Cleaved Caspase-3 (p <.05) in Dex-induced cells. MiR-222-3p inhibitor reversed the antagonistic effect of Tectorigenin on Dex. The study demonstrates that Tectorigenin inhibits apoptosis of Dex-induced 9HTE cells by up-regulating the expression of miR-222-3p, which involves with the MAPK pathway.

Early life microbial exposures and allergy risks: opportunities for prevention

Allergies, including asthma, food allergy and atopic dermatitis, are increasing in prevalence, particularly in westernized countries. Although a detailed mechanistic explanation for this increase is lacking, recent evidence indicates that, in addition to genetic predisposition, lifestyle changes owing to modernization have an important role. Such changes include increased rates of birth by caesarean delivery, increased early use of antibiotics, a westernized diet and the associated development of obesity, and changes in indoor and outdoor lifestyle and activity patterns. Most of these factors directly and indirectly impact the formation of a diverse microbiota, which includes bacterial, viral and fungal components; the microbiota has a leading role in shaping (early) immune responses. This default programme is markedly disturbed under the influence of environmental and lifestyle risk factors. Here, we review the most important allergy risk factors associated with changes in our exposure to the microbial world and the application of this knowledge to allergy prevention strategies.

Global implementation of the world health organization's International Classification of Diseases (ICD)-11: The allergic and hypersensitivity conditions model

The International Classification of Diseases (ICD) provides a common language for use worldwide as a diagnostic and classification tool for epidemiology, clinical purposes and health management. Since its first edition, the ICD has maintained a framework distributing conditions according to topography, with the result that some complex conditions, such as allergies and hypersensitivity disorders (A/H) including anaphylaxis, have been poorly represented. The change in hierarchy in ICD-11 permitted the construction of the pioneer section addressed to A/H, which may result in more accurate mortality and morbidity statistics, including more accurate accounting for mortality due to anaphylaxis, strengthen classification, terminology and definitions. The ICD-11 was presented and adopted by the 72nd World Health Assembly in May 2019, and the implementation is ongoing worldwide. We here present the outcomes from an online survey undertaken to reach out the allergy community worldwide in order to peer review the terminology, classification and definitions of A/H introduced into ICD-11 and to support their global implementation. Data are presented here for 406 respondents from 74 countries. All of the subsections of the new A/H section of the ICD-11 had been considered with good accuracy by the majority of respondents. We believe that, in addition to help during the implementation phase, all the comments provided will help to improve the A/H classification and to increase awareness by different disciplines of what actions are needed to ensure more accurate epidemiological data and better clinical management of A/H patients.

Asthma and anaphylaxis

PURPOSE OF REVIEW

Both asthma and anaphylaxis are recognized noncommunicable hypersensitivity conditions, which should be correctly diagnosed and treated/controlled in order to decrease avoidable deaths. Nevertheless, their association is not completely clear. We here propose to review the current and new evidence-based data of asthma and anaphylaxis in the view of the new knowledge in the field that can support the quality practice and empower allergists and health professionals in treating symptoms and preventing death.

RECENT FINDINGS

Hypersensitivity life-threatening conditions, such as anaphylaxis and asthma can coexist, mimic or worse each other. Asthma itself is not a strong predictor of more severe anaphylaxis. However, poor asthma control associated with more severe anaphylaxis reactions in all ages. In children, asthma is associated with the severity and recurrences of anaphylactic reactions.

SUMMARY

Although recent data point for the association between asthma and anaphylaxis, we still do not have harmonized evidence to confirm if we are dealing with two independent comorbidities one worsening each other. However, as far as this review is covering two relevant public health problems in the field of allergy, it is mandatory put in place decisions supporting recommendations to better manage the affected patients and reduce the risk.General strategies should include regular notification of this association, optimization of the classification and coding for anaphylaxis and asthma (new ICD 11 allergy codes) in order to harmonize epidemiological stratified data, early diagnosis of asthma in childhood, regular investigation of asthma in cases of anaphylaxis and optimization of the asthma control and lung function for all patients with indication to provocation tests, desensitization or allergen immunotherapy regardless to the trigger. Implementation of these strategies will involve national and international support for ongoing efforts in relationship with networks of centres of excellence to provide personalized management for the most at-risk patients and prevent death.

Outpatient Management of Bronchial Asthma: A Comparative Analysis Between Guideline-Directed Management and Usual Management

Background

Bronchial asthma is a common controllable disease that causes a serious economic and social burden. The Global Initiative for Asthma (GINA) was developed to help guide clinicians in appropriate management of asthma. Despite the existence of published guidelines, common practice in many primary care clinics follows usual care based on clinical gestalt. This study aims to determine if there is a statistically significant difference in outcomes between patients receiving guideline-directed therapy when compared to those receiving usual clinician therapy.

Methods

A total of 300 patients were included in this study. Among them, 139 patients received guideline-directed medical therapy (GDMT group) and 161 received usual medical therapy (UMT group). Logistic regression models were utilized to determine if there was a significant difference in outcomes for patients comparing number of exacerbations and number of hospitalizations.

Results

More patients in GDMT group suffered from recorded exacerbations in the prior year with 43.9% having one, 3.6% having two, and 0.7% having three, compared to the frequencies of exacerbations in the UMT group (29.2%, 1.9%, and 1.2%, respectively) (P < 0.05). Cumulative number of hospitalizations due to asthma exacerbations in the prior year was also higher in GDMT group compared to the UMT group (one in 5.8% GDMT vs. 3.1% UMT; two in 0.0% GDMT vs. 0.6% UMT) without statistically significant difference (P = 0.349).

Conclusions

Primary care providers’ adherence to the 2018 GINA guidelines for asthma treatment did not offer benefit to patient outcomes, such as number of exacerbations or hospitalizations, compared to the usual medical care of bronchial asthma. Patient-tailored care may offer reduction in the rates of exacerbations and hospitalization.

EAACI Allergen Immunotherapy User's Guide

Allergen immunotherapy is a cornerstone in the treatment of allergic children. The clinical efficiency relies on a well-defined immunologic mechanism promoting regulatory T cells and downplaying the immune response induced by allergens. Clinical indications have been well documented for respiratory allergy in the presence of rhinitis and/or allergic asthma, to pollens and dust mites. Patients who have had an anaphylactic reaction to hymenoptera venom are also good candidates for allergen immunotherapy. Administration of allergen is currently mostly either by subcutaneous injections or by sublingual administration. Both methods have been extensively studied and have pros and cons. Specifically in children, the choice of the method of administration according to the patient's profile is important. Although allergen immunotherapy is widely used, there is a need for improvement. More particularly, biomarkers for prediction of the success of the treatments are needed. The strength and efficiency of the immune response may also be boosted by the use of better adjuvants. Finally, novel formulations might be more efficient and might improve the patient's adherence to the treatment. This user's guide reviews current knowledge and aims to provide clinical guidance to healthcare professionals taking care of children undergoing allergen immunotherapy.

Effects of Acupressure on Symptoms Relief and Improving Sleep Quality in Pediatric Patients With Allergic Rhinitis

Current pharmacological management of allergic rhinitis cannot completely provide relief from the symptoms and is usually accompanied by undesirable side effects. Complementary and alternative medicine approach has been evaluated and applied for allergic rhinitis frequently. We aim to investigate whether acupressure could be used as daily nursing care practice to reduce the severity of allergic rhinitis symptoms and improve sleep quality in pediatric patients with allergic rhinitis. Patients were divided into the acupressure and control groups randomly. Acupressure on 6 the acupoints was administered at home every night for 4 weeks in the acupressure group after attending a training program. Participants in the control group maintained their daily routine. A questionnaire was used to collect demographic and clinical characteristics, and to assess the symptom scores and sleep quality at baseline, week 2, and week 4 after intervention. Results of the generalized estimating equation model showed there were significant group effects on the total nasal symptom scores, sneezing, nasal congestion, itching of nose and palate, and watery eyes over the study period (all Ps < .05). From baseline to 2 weeks, all the aforementioned symptoms and red eyes, sleep quality, and allergic rhinitis classification more improved in the acupressure group than in the control group and the effect in the acupressure group was maintained through 4 weeks after intervention. Our results showed a significant reduction in the symptoms of allergic rhinitis and improvement in sleep quality after acupressure treatment with no adverse effects. Acupressure could be used as daily nursing care practice for this chronic, lifetime disorder.

Bronchiolitis needs a revisit: Distinguishing between virus entities and their treatments

Current data indicate that the “bronchiolitis” diagnosis comprises more than one condition. Clinically, pathophysiologically, and even genetically three main clusters of patients can be identified among children suffering from severe bronchiolitis (or first wheezing episode): (a) respiratory syncytial virus (RSV)‐induced bronchiolitis, characterized by young age of the patient, mechanical obstruction of the airways due to mucus and cell debris, and increased risk of recurrent wheezing. For this illness, an effective prophylactic RSV‐specific monoclonal antibody is available; (b) rhinovirus‐induced wheezing, associated with atopic predisposition of the patient and high risk of subsequent asthma development, which may, however, be reversed with systemic corticosteroids in those with severe illness; and (c) wheeze due to other viruses, characteristically likely to be less frequent and severe. Clinically, it is important to distinguish between these partially overlapping patient groups as they are likely to respond to different treatments. It appears that the first episode of severe bronchiolitis in under 2‐year‐old children is a critical event and an important opportunity for designing secondary prevention strategies for asthma. As data have shown bronchiolitis cannot simply be diagnosed using a certain cutoff age, but instead, as we suggest, using the viral etiology as the differentiating factor.

Protective Effects of Casticin From Vitex trifolia Alleviate Eosinophilic Airway Inflammation and Oxidative Stress in a Murine Asthma Model

Casticin has been isolated from Vitex trifolia and found to have anti-inflammatory and anti-tumor properties. We also previously discovered that casticin can reduce pro-inflammatory cytokines and ICAM-1 expression in inflammatory pulmonary epithelial cells. In the present study, we evaluated whether casticin reduced airway hyper-responsiveness (AHR), airway inflammation, and oxidative stress in the lungs of a murine asthma model and alleviated inflammatory and oxidative responses in tracheal epithelial cells. Female BALB/c mice were randomly divided into five groups: normal controls, ovalbumin (OVA)-induced asthma, and OVA-induced asthma treated with intraperitoneal injection of casticin (5 or 10 mg/kg) or prednisolone (5 mg/kg). Casticin reduced AHR, goblet cell hyperplasia, and oxidative responses in the lungs of mice with asthma. Mechanistic studies revealed that casticin attenuated the levels of Th2 cytokine in bronchoalveolar lavage fluids and regulated the expression of Th2 cytokine and chemokine genes in the lung. Casticin also significantly regulated oxidative stress and reduced inflammation in the lungs of mice with asthma. Consequently, inflammatory tracheal epithelial BEAS-2B cells treated with casticin had significantly suppressed levels of pro-inflammatory cytokines and eotaxin, and reduced THP-1 monocyte cell adherence to BEAS-2B cells via suppressed ICAM-1 expression. Thus, casticin is a powerful immunomodulator, ameliorating pathological changes by suppressing Th2 cytokine expression in mice with asthma.

The Southern Sweden Adolescent Allergy-Cohort: Prevalence of allergic diseases and cross-sectional associations with individual and social factors

OBJECTIVES

Asthma and allergic diseases are the most frequent chronic diseases in childhood worldwide, and considered a burden for the affected children and their families. The diseases impose an economic burden on society if not diagnosed and treated properly and management of and these diseases are challenging for healthcare professionals. The aim of the present investigation was to assess the prevalence of allergic diseases in an unselected cohort of adolescents in southern Sweden. Additionally, associations with sociodemographic factors were investigated, as well as impact on daily life.

METHODS

This cross-sectional study was based on a cohort of n = 1 530 school children, aged 13 to 14, from 13 municipalities in southern Sweden. Data were collected through web-based questionnaires.

RESULTS

Of all children 32% reported at least one allergic disease. 67% reported one allergic disease and 33% reported more than one. No allergy-related disease were reported by 68%. Current asthma was reported by 9.8% and current rhino-conjunctivitis was reported by 13%. The prevalence of food hypersensitivity was 12% and the prevalence of eczema was 11%. One to three wheezing attacks were reported from 55% and 40% reported more than four attacks of wheezing in the preceding year. The self-reported allergic diseases were diagnosed by a doctor in; 36% (food hypersensitivity) to 69% (rhinoconjunctivitis) of the cases.

CONCLUSIONS

A high number of affected children were identified. Some children being undiagnosed and some not receiving satisfactory treatment. These results suggest that additional studies to evaluate treatment procedures in order to improve healthcare for allergic children are warranted.