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Burgel PR, Bush A. Reversal of Bronchiectasis in Children: Early Intervention May Stop the Vicious Circle! Am J Respir Crit Care Med 2024; 210:17-18. [PMID: 38717794 PMCID: PMC11197074 DOI: 10.1164/rccm.202404-0764ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 05/08/2024] [Indexed: 06/27/2024] Open
Affiliation(s)
- Pierre-Régis Burgel
- Insitut Cochin, Inserm U1016 Université Paris-Cité Paris, France
- Respiratory Medicine and Cystic Fibrosis National Reference Center Cochin Hospital Paris, France
| | - Andrew Bush
- National Heart and Lung Institute Imperial College London London, United Kingdom
- Imperial Centre for Paediatrics and Child Health Imperial College London London, United Kingdom
- Royal Brompton Hospital London, United Kingdom
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2
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Weary TE, Pappas T, Tusiime P, Tuhaise S, Ross E, Gern JE, Goldberg TL. High frequencies of nonviral colds and respiratory bacteria colonization among children in rural Western Uganda. Front Pediatr 2024; 12:1379131. [PMID: 38756971 PMCID: PMC11096560 DOI: 10.3389/fped.2024.1379131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/19/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction Respiratory illness is the most common childhood disease globally, especially in developing countries. Previous studies have detected viruses in approximately 70-80% of respiratory illnesses. Methods In a prospective cohort study of 234 young children (ages 3-11 years) and 30 adults (ages 22-51 years) in rural Western Uganda sampled monthly from May 2019 to August 2021, only 24.2% of nasopharyngeal swabs collected during symptomatic disease had viruses detectable by multiplex PCR diagnostics and metagenomic sequencing. In the remaining 75.8% of swabs from symptomatic participants, we measured detection rates of respiratory bacteria Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae by quantitative PCR. Results 100% of children tested positive for at least one bacterial species. Detection rates were 87.2%, 96.8%, and 77.6% in children and 10.0%, 36.7%, and 13.3% for adults for H. influenzae, M. catarrhalis, and S. pneumoniae, respectively. In children, 20.8% and 70.4% were coinfected with two and three pathogens, respectively, and in adults 6.7% were coinfected with three pathogens but none were coinfected with two. Detection of any of the three pathogens was not associated with season or respiratory symptoms severity, although parsing detection status by symptoms was challenged by children experiencing symptoms in 80.3% of monthly samplings, whereas adults only reported symptoms 26.6% of the time. Pathobiont colonization in children in Western Uganda was significantly more frequent than in children living in high-income countries, including in a study of age-matched US children that utilized identical diagnostic methods. Detection rates were, however, comparable to rates in children living in other Sub-Saharan African countries. Discussion Overall, our results demonstrate that nonviral colds contribute significantly to respiratory disease burden among children in rural Uganda and that high rates of respiratory pathobiont colonization may play a role. These conclusions have implications for respiratory health interventions in the area, such as increasing childhood immunization rates and decreasing air pollutant exposure.
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Affiliation(s)
- Taylor E. Weary
- Department of Pathobiological Sciences, University of Wisconsin School of Veterinary Medicine, Madison, WI, United States
| | - Tressa Pappas
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | | | | | | | - James E. Gern
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Tony L. Goldberg
- Department of Pathobiological Sciences, University of Wisconsin School of Veterinary Medicine, Madison, WI, United States
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3
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Ukkonen RM, Renko M, Kuitunen I. Azithromycin for acute bronchiolitis and wheezing episodes in children - a systematic review with meta-analysis. Pediatr Res 2024; 95:1441-1447. [PMID: 38066246 PMCID: PMC11126380 DOI: 10.1038/s41390-023-02953-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 11/07/2023] [Accepted: 11/13/2023] [Indexed: 05/26/2024]
Abstract
BACKGROUND The aim of this systematic review and meta-analysis was to analyse the efficacy of azithromycin in acute bronchiolitis and wheezing. METHODS PubMed, Scopus, and Web of Science databases were searched for randomized controlled trials comparing azithromycin to placebo in children <2 years of age. Main outcomes were progress of acute wheezing episode and recurrence of wheezing. We used random-effects model to calculate mean difference (MD) with 95% confidence interval (CI) or risk ratios (RR) with CI. RESULTS We screened 1604 abstracts and included 7 studies. Risk of bias was low in three and had some concerns in four studies. Need for intensive care unit treatment was assessed in four studies (446 children) and the risk difference was 0.0% (CI -2.0 to 2.0; low quality evidence). Hospitalization duration was -0.27 days shorter in the azithromycin group (MD-0.27, CI -0.47 to -0.07; three studies; moderate quality evidence). Azithromycin did not prevent recurrence of wheezing (RR 0.84, CI 0.45-1.56; three studies), hospital readmissions (RR 1.14, CI 0.82-1.60; four studies). CONCLUSIONS We found moderate quality evidence that azithromycin may reduce hospitalization duration. Low certainty evidence suggests that azithromycin does not reduce the need for intensive care unit treatment. Furthermore, azithromycin did not prevent wheezing recurrence. IMPACT Azithromycin may reduce hospitalization time in acute bronchiolitis and wheezing episodes among children aged less than two. Azithromycin administrated during the acute wheezing period, does not have preventive effect on wheezing recurrence. Azithromycin seemed to have similar adverse event profile than placebo. Future studies with clinically relevant outcomes, and sufficient sample sizes are needed, before implementing azithromycin into clinical use.
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Affiliation(s)
- Rosa-Maria Ukkonen
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Kuopio, Finland
| | - Marjo Renko
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Kuopio, Finland
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Ilari Kuitunen
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Kuopio, Finland.
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland.
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Smith T, Mills K, Cober MP, Fenn NE, Hill C, King M, Pauley JL, Eiland L, Sierra C, Omecene NE. Updates in the treatment of asthma in pediatrics: A review for pharmacists. Am J Health Syst Pharm 2024; 81:e210-e219. [PMID: 38146826 DOI: 10.1093/ajhp/zxad326] [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: 12/20/2023] [Indexed: 12/27/2023] Open
Abstract
PURPOSE The purpose of this review is to summarize the management of asthma in children and to highlight different guideline-based approaches. This review also discusses literature regarding the use of corticosteroids, both inhaled and systemic, as well as biologic agents, in asthma management. SUMMARY Asthma is a common chronic respiratory condition in the pediatric population and has evolved into a highly patient-specific disease. Of the 2 main asthma guidelines, one developed by the National Asthma Education and Prevention Program was recently published as a focused update in 2020. The other, from the Global Initiative for Asthma, focuses on a global strategy for management and prevention, with the most recent update in 2023. Both reports discuss diagnosis, assessment, and treatment of asthma in adults and children. Treatment is designed as a stepwise approach in both reports, although there are key differences. This article focuses on gaps in these guidelines, including the use of bronchodilators and inhaled corticosteroids with single maintenance and reliever therapy and long-acting muscarinic antagonists in children. It also reviews treatment in children under 5 years of age, although recommendations are limited due to a lack of evidence in this age group. Finally, this review discusses considerations for emerging treatments, including biologics, for patients who are difficult to treat. CONCLUSION New treatment strategies and agents have emerged in the treatment of pediatric asthma. Pharmacists play a key role in providing education about, dispensing, and recommending the newest evidence-based treatment options for children.
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Affiliation(s)
- Tara Smith
- HCA Florida West Healthcare, Pensacola, FL, USA
| | | | - M Petrea Cober
- Akron Children's Hospital, Akron, OH, and College of Pharmacy, Northeast Ohio Medical University, Rosstown, OH, USA
| | - Norman E Fenn
- Manchester University College of Pharmacy, Natural, and Health Sciences, Fort Wayne, IN
- Parkview Women's and Children's Hospital, Fort Wayne, IN, USA
| | - Carolyn Hill
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Morgan King
- Cleveland Clinic Fairview Hospital, Cleveland, OH, USA
| | | | - Lea Eiland
- Department of Pharmacy Practice, Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - Caroline Sierra
- Loma Linda University School of Pharmacy, Lorna Linda, CA, USA
| | - Nicole E Omecene
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
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5
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Shi C, Wu MH, Zuo A, Yang MM, Jiang RR. Clinical analysis of 114 cases of bronchiolitis in infants. World J Clin Cases 2023; 11:8284-8290. [PMID: 38130614 PMCID: PMC10731204 DOI: 10.12998/wjcc.v11.i35.8284] [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: 09/22/2023] [Revised: 10/12/2023] [Accepted: 12/04/2023] [Indexed: 12/14/2023] Open
Abstract
BACKGROUND Bronchiolitis is a common lower respiratory tract infection in infants and young children. Severe cases may be accompanied by obvious dyspnea and oxygen saturation decline. AIM To summarize the clinical features, standard diagnosis, and treatment of bronchiolitis. METHODS This is a retrospective analysis of 114 pediatric patients (74 males, 40 females) who were first diagnosed as having bronchioles at the Department of Pediatrics of Tongling Maternal and Child Health Hospital from January 2019 to December 2019. The clinical features, imaging features, treatment, and other clinical data were recorded and analyzed. RESULTS The age of onset of the disease was mainly from 1 mo to 6 mo (75.4%), and the time to hospital visit was mostly from the 2nd day to the 4th day of the course of the disease (75.4%). Lung imaging examination showed increase in lung texture, fuzzy (93.8%). The main treatment was atomization therapy: Budesonide combined with terbutaline (45.6%) and budesonide combined with salbutamol (38.5%). The average hospitalization time was 7.1 ± 2.4 d, and the overall cure rate was 94.7%. In patients without bacterial infection, the use of antibiotics significantly prolonged the length of hospital stay (7.8 ± 2.5 d vs 5.7 ± 1.8 d) and improved the cure rate (98.3% vs 87.9%, P < 0.05). CONCLUSION Infants with bronchiolitis are mainly male and tend to have a good prognosis. However, the unneeded use of antibiotics may prolong the length of hospital stay significantly, which imposes the burden both on the patients and hospital system.
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Affiliation(s)
- Cheng Shi
- Department of Pediatrics, Tongling Maternal and Child Health Hospital, Tongling 244000, Anhui Province, China
| | - Meng-Hua Wu
- Department of Pediatrics, Tongling Maternal and Child Health Hospital, Tongling 244000, Anhui Province, China
| | - An Zuo
- Department of Pediatrics, Tongling Maternal and Child Health Hospital, Tongling 244000, Anhui Province, China
| | - Mi-Mi Yang
- Department of Pediatrics, Tongling Maternal and Child Health Hospital, Tongling 244000, Anhui Province, China
| | - Rong-Rong Jiang
- Department of Pediatrics, Tongling Maternal and Child Health Hospital, Tongling 244000, Anhui Province, China
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Salehian S, Fleming L, Saglani S, Custovic A. Phenotype and endotype based treatment of preschool wheeze. Expert Rev Respir Med 2023; 17:853-864. [PMID: 37873657 DOI: 10.1080/17476348.2023.2271832] [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: 03/17/2023] [Accepted: 10/13/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Preschool wheeze (PSW) is a significant public health issue, with a high presentation rate to emergency departments, recurrent symptoms, and severe exacerbations. A heterogenous condition, PSW comprises several phenotypes that may relate to a range of pathobiological mechanisms. However, treating PSW remains largely generalized to inhaled corticosteroids and a short acting beta agonist, guided by symptom-based labels that often do not reflect underlying pathways of disease. AREAS COVERED We review the observable features and characteristics used to ascribe phenotypes in children with PSW and available pathobiological evidence to identify possible endotypes. These are considered in the context of treatment options and future research directions. The role of machine learning (ML) and modern analytical techniques to identify patterns of disease that distinguish phenotypes is also explored. EXPERT OPINION Distinct clusters (phenotypes) of severe PSW are characterized by different underlying mechanisms, some shared and some unique. ML-based methodologies applied to clinical, biomarker, and environmental data can help design tools to differentiate children with PSW that continues into adulthood, from those in whom wheezing resolves, identifying mechanisms underpinning persistence and resolution. This may help identify novel therapeutic targets, inform mechanistic studies, and serve as a foundation for stratification in future interventional therapeutic trials.
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Affiliation(s)
- Sormeh Salehian
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Adnan Custovic
- NIHR Imperial Biomedical Research Centre (BRC), London, UK
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7
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Bush A. Basic clinical management of preschool wheeze. Pediatr Allergy Immunol 2023; 34:e13988. [PMID: 37492909 DOI: 10.1111/pai.13988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 07/27/2023]
Abstract
Preschool wheeze is very common and often difficult to treat. Most children do not require any investigations; only a detailed history and physical examination to ensure an alternative diagnosis is not being missed; and the differential diagnosis, and hence investigation protocols for the child in whom a major illness is suspected, shows geographical variation. The pattern of symptoms may be divided into episodic viral and multiple trigger to guide treatment, but the pattern of symptoms must be re-assessed regularly. However, symptom patterns are a poor guide to underlying pathology. Attention to the proper use of spacers, and adverse environmental exposures such as tobacco smoke exposure, is essential. There are no disease-modifying therapies, so therapy is symptomatic. This paper reviews recent advances in treatment, including new data on the place of leukotriene receptor antagonists, prednisolone for acute attacks of wheeze, and antibiotics, based on new attempts to understand the underlying pathology in a way that is clinically practical.
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Affiliation(s)
- Andrew Bush
- Imperial College, London, UK
- National Heart and Lung Institute, London, UK
- Royal Brompton Harefield NHS Foundation Trust, London, UK
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8
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Smith FM, Saglani S. Demystifying controversies in preschool wheeze. Expert Rev Respir Med 2023; 17:1023-1031. [PMID: 37979137 DOI: 10.1080/17476348.2023.2283128] [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: 05/30/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Wheezing disorders in preschool children are common. Current treatment approaches assume all preschool wheezers are the same and will respond to a short course of oral corticosteroids (OCS) during acute attacks and subsequent maintenance inhaled corticosteroids (ICS) to prevent future attacks. But we have increasing evidence showing preschool wheezing disorders are markedly heterogeneous and the response to corticosteroids either during acute attacks or as maintenance therapy can be variable between patients and is determined by disease severity and underlying pathological phenotype. AREAS COVERED The aim of this review is to discuss recent evidence which will help to explain a few critical pathophysiological concepts that are often misunderstood, thus helping to demystify the controversies that often surround preschool wheezing disorders and can contribute to ineffective management. EXPERT OPINION Preschool wheezing disorders are distinct from school-age allergic asthma. There is little evidence to support the use of oral corticosteroids for acute attacks. A staged approach to confirm the diagnosis, and objective tests to determine the pathological phenotype of preschool wheeze is essential prior to initiating maintenance therapy to control symptoms and prevent attacks in children with recurrent preschool wheeze.
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Affiliation(s)
- Frank M Smith
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Sejal Saglani
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
- National Heart & Lung Institute, Imperial College London, London, UK
- Imperial Centre for Paediatrics and Child Health, Imperial College London, London, UK
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9
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Scotney E, Fleming L, Saglani S, Sonnappa S, Bush A. Advances in the pathogenesis and personalised treatment of paediatric asthma. BMJ MEDICINE 2023; 2:e000367. [PMID: 37841968 PMCID: PMC10568124 DOI: 10.1136/bmjmed-2022-000367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 05/05/2023] [Indexed: 10/17/2023]
Abstract
The diversity of pathology of severe paediatric asthma demonstrates that the one-size-fits-all approach characterising many guidelines is inappropriate. The term "asthma" is best used to describe a clinical syndrome of wheeze, chest tightness, breathlessness, and sometimes cough, making no assumptions about underlying pathology. Before personalising treatment, it is essential to make the diagnosis correctly and optimise basic management. Clinicians must determine exactly what type of asthma each child has. We are moving from describing symptom patterns in preschool wheeze to describing multiple underlying phenotypes with implications for targeting treatment. Many new treatment options are available for school age asthma, including biological medicines targeting type 2 inflammation, but a paucity of options are available for non-type 2 disease. The traditional reliever treatment, shortacting β2 agonists, is being replaced by combination inhalers containing inhaled corticosteroids and fast, longacting β2 agonists to treat the underlying inflammation in even mild asthma and reduce the risk of asthma attacks. However, much decision making is still based on adult data extrapolated to children. Better inclusion of children in future research studies is essential, if children are to benefit from these new advances in asthma treatment.
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Affiliation(s)
- Elizabeth Scotney
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Samatha Sonnappa
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Andrew Bush
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
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10
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Goulao B, Duncan A, Innes K, Ramsay CR, Kahan BC. Using re-randomisation designs to increase the efficiency and applicability of retention studies within trials: a case study. Trials 2023; 24:299. [PMID: 37118802 PMCID: PMC10148456 DOI: 10.1186/s13063-023-07323-y] [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: 06/06/2022] [Accepted: 04/22/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Poor retention in randomised trials can lead to serious consequences to their validity. Studies within trials (SWATs) are used to identify the most effective interventions to increase retention. Many interventions could be applied at any follow-up time point, but SWATs commonly assess interventions at a single time point, which can reduce efficiency. METHODS The re-randomisation design allows participants to be re-enrolled and re-randomised whenever a new retention opportunity occurs (i.e. a new follow-up time point where the intervention could be applied). The main advantages are as follows: (a) it allows the estimation of an average effect across time points, thus increasing generalisability; (b) it can be more efficient than a parallel arm trial due to increased sample size; and (c) it allows subgroup analyses to estimate effectiveness at different time points. We present a case study where the re-randomisation design is used in a SWAT. RESULTS In our case study, the host trial is a dental trial with two available follow-up points. The Sticker SWAT tests whether adding the trial logo's sticker to the questionnaire's envelope will result in a higher response rate compared with not adding the sticker. The primary outcome is the response rate to postal questionnaires. The re-randomisation design could double the available sample size compared to a parallel arm trial, resulting in the ability to detect an effect size around 28% smaller. CONCLUSION The re-randomisation design can increase the efficiency and generalisability of SWATs for trials with multiple follow-up time points.
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Affiliation(s)
- Beatriz Goulao
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland.
| | - Anne Duncan
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Karen Innes
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
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Lange KM, Kasza J, Sullivan TR, Yelland LN. Partially clustered designs for clinical trials: Unifying existing designs using consistent terminology. Clin Trials 2023; 20:99-110. [PMID: 36628406 PMCID: PMC10021130 DOI: 10.1177/17407745221146987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Clinical trial designs based on the assumption of independent observations are well established. Clustered clinical trial designs, where all observational units belong to a cluster and outcomes within clusters are expected to be correlated, have also received considerable attention. However, many clinical trials involve partially clustered data, where only some observational units belong to a cluster. Examples of such trials occur in neonatology, where participants include infants from both singleton and multiple births, and ophthalmology, where one or two eyes per participant may need treatment. Partial clustering can also arise in trials of group-based treatments (e.g. group education or counselling sessions) or treatments administered individually by a discrete number of health care professionals (e.g. surgeons or physical therapists), when this is compared to an unclustered control arm. Trials involving partially clustered data have received limited attention in the literature and the current lack of standardised terminology may be hampering the development and dissemination of methods for designing and analysing these trials. METHODS AND EXAMPLES In this article, we present an overarching definition of partially clustered trials, bringing together several existing trial designs including those for group-based treatments, clustering due to facilitator effects and the re-randomisation design. We define and describe four types of partially clustered trial designs, characterised by whether the clustering occurs pre-randomisation or post-randomisation and, in the case of pre-randomisation clustering, by the method of randomisation that is used for the clustered observations (individual randomisation, cluster randomisation or balanced randomisation within clusters). Real life examples are provided to highlight the occurrence of partially clustered trials across a variety of fields. To assess how partially clustered trials are currently reported, we review published reports of partially clustered trials. DISCUSSION Our findings demonstrate that the description of these trials is often incomplete and the terminology used to describe the trial designs is inconsistent, restricting the ability to identify these trials in the literature. By adopting the definitions and terminology presented in this article, the reporting of partially clustered trials can be substantially improved, and we present several recommendations for reporting these trial designs in practice. Greater awareness of partially clustered trials will facilitate more methodological research into their design and analysis, ultimately improving the quality of these trials.
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Affiliation(s)
- Kylie M Lange
- School of Public Health, The University of Adelaide, Adelaide, SA, Australia.,Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Jessica Kasza
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Thomas R Sullivan
- School of Public Health, The University of Adelaide, Adelaide, SA, Australia.,Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Lisa N Yelland
- School of Public Health, The University of Adelaide, Adelaide, SA, Australia.,Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
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Bisgaard H, Chawes B, Stokholm J, Mikkelsen M, Schoos AMM, Bønnelykke K. 25 Years of translational research in the Copenhagen Prospective Studies on Asthma in Childhood (COPSAC). J Allergy Clin Immunol 2023; 151:619-633. [PMID: 36642652 DOI: 10.1016/j.jaci.2022.11.022] [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: 06/07/2022] [Revised: 10/28/2022] [Accepted: 11/04/2022] [Indexed: 01/15/2023]
Abstract
The Copenhagen Prospective Studies on Asthma in Childhood (COPSAC) mother-child cohorts have provided a foundation of 25 years of research on the origins, prevention, and natural history of childhood asthma and related disorders. COPSAC's approach is characterized by clinical translational research with longitudinal deep phenotyping and exposure assessments from pregnancy, in combination with multi-omic data layers and embedded randomized controlled trials. One trial showed that fish oil supplementation during pregnancy prevented childhood asthma and identified pregnant women with the highest benefits from supplementation, thereby creating the potential for personalized prevention. COPSAC revealed that airway colonization with pathogenic bacteria in early life is associated with an increased risk of asthma. Further, airway bacteria were shown to be a trigger of acute asthma-like symptoms, with benefit from antibiotic treatment. COPSAC identified an immature gut microbiome in early life as a risk factor for asthma and allergy and further demonstrated that asthma can be predicted by infant lung function. At a molecular level, COPSAC has identified novel susceptibility genes, early immune deviations, and metabolomic alterations associated with childhood asthma. Thus, the COPSAC research program has enhanced our understanding of the processes causing childhood asthma and has suggested means of personalized prevention and treatment.
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Affiliation(s)
- Hans Bisgaard
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Bo Chawes
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Stokholm
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark; Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
| | - Marianne Mikkelsen
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Ann-Marie Malby Schoos
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark; Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
| | - Klaus Bønnelykke
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
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Wu S, Tian X, Mao Q, Peng C. Azithromycin attenuates wheezing after pulmonary inflammation through inhibiting histone H3K27me3 hypermethylation mediated by EZH2. Clin Epigenetics 2023; 15:12. [PMID: 36691058 PMCID: PMC9872437 DOI: 10.1186/s13148-023-01430-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 01/16/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Histone methylation modification plays an irreplaceable role in the wheezing diseases. The aim of this study was to explore whether azithromycin (AZM) attenuates post-inflammatory wheezing through inhibiting hypermethylation of histone H3K27me3 mediated by EZH2. RESULTS A randomized controlled trial was conducted on 227 children who underwent fiber-optic bronchoscopy, and bronchoalveolar lavage fluid (BALF) was collected for analyses. The expressions of IL-6, IL-2, NF-κB P65, EZH2 and H3K27me3 in the BALF of wheezing cases were significantly increased when compared with levels in non-wheezing cases (P < 0.05), while IL-10 was decreased (P < 0.05). AZM attenuated the overexpression of NF-κB P65, EZH2 and H3K27me3 in wheezing cases (P < 0.05) and shortened the time of wheezing in wheezing cases (P < 0.05). An in vitro model of inflammation was established using rat alveolar macrophages induced by lipopolysaccharide (LPS). AZM, SN50 (a NK-κB inhibitor) and GSK126 (an EZH2 inhibitor) attenuated the overexpression of EZH2, NF-κB P65 and H3K27me3 induced by LPS in rat alveolar macrophages (P < 0.05). AZM, SN50 and GSK126 normalized the decreased expression of IL-10 induced by LPS in the same samples (P < 0.05). Co-immunoprecipitation results showed that H3K27me3 interacted with EZH2 and NF-κB P65, and immunofluorescence data showed that AZM and SN50 inhibited LPS-induced NF-κB P65 nuclear translocation in rat alveolar macrophages. CONCLUSION Histone H3K27me3 hypermethylation mediated by EZH2 may be involved in wheezing after pulmonary inflammation. AZM attenuated wheezing after pulmonary inflammation by inhibiting NF-κB P65-related hypermethylation of H3K27me3 mediated by EZH2.
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Affiliation(s)
- Shuqi Wu
- Department of Pediatrics, Guizhou Children's Hospital, Affiliated Hospital of Zunyi Medical University, 149 Dalian Street, Zunyi, 563000, Guizhou, People's Republic of China
| | - Xiaochun Tian
- Department of Pediatrics, Guizhou Children's Hospital, Affiliated Hospital of Zunyi Medical University, 149 Dalian Street, Zunyi, 563000, Guizhou, People's Republic of China
| | - Qian Mao
- Department of Pediatrics, Guizhou Children's Hospital, Affiliated Hospital of Zunyi Medical University, 149 Dalian Street, Zunyi, 563000, Guizhou, People's Republic of China
| | - Chang Peng
- Department of Pediatrics, Guizhou Children's Hospital, Affiliated Hospital of Zunyi Medical University, 149 Dalian Street, Zunyi, 563000, Guizhou, People's Republic of China.
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14
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Bønnelykke K, Chawes B, Stokholm J, Følsgaard NV, Schoos AMM, Mikkelsen M. In lasting tribute: Dr Hans Bisgaard, January 24, 1955, to September 8, 2022. J Allergy Clin Immunol 2023; 151:S0091-6749(22)02554-4. [PMID: 36635204 DOI: 10.1016/j.jaci.2022.12.806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/05/2022] [Accepted: 12/13/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Klaus Bønnelykke
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Bo Chawes
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Stokholm
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Nilofar V Følsgaard
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Ann-Marie M Schoos
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Mikkelsen
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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15
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Bosco A. Emerging role for interferons in respiratory viral infections and childhood asthma. Front Immunol 2023; 14:1109001. [PMID: 36895568 PMCID: PMC9989033 DOI: 10.3389/fimmu.2023.1109001] [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: 11/27/2022] [Accepted: 02/02/2023] [Indexed: 02/23/2023] Open
Abstract
Respiratory syncytial virus (RSV) and Rhinovirus (RV) infections are major triggers of severe lower respiratory illnesses (sLRI) in infants and children and are strongly associated with the subsequent development of asthma. Decades of research has focused on the role of type I interferons in antiviral immunity and ensuing airway diseases, however, recent findings have highlighted several novel aspects of the interferon response that merit further investigation. In this perspective, we discuss emerging roles of type I interferons in the pathogenesis of sLRI in children. We propose that variations in interferon response patterns exist as discrete endotypes, which operate locally in the airways and systemically through a lung-blood-bone marrow axis. We discuss new insights into the role of interferons in immune training, bacterial lysate immunotherapy, and allergen-specific immunotherapy. Interferons play complex and diverse roles in the pathogenesis of sLRI and later asthma, providing new directions for mechanistic studies and drug development.
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Affiliation(s)
- Anthony Bosco
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, AZ, United States.,Department of Immunobiology, The University of Arizona College of Medicine, Tucson, AZ, United States
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16
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Asthma Management in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:9-18. [PMID: 36334702 DOI: 10.1016/j.jaip.2022.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/05/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022]
Abstract
Asthma is a common, complex heterogeneous disease often beginning in early life and is characterized by reversible airflow obstruction. The phenotypic differences that exist in children with asthma may impact underlying comorbid conditions and pharmacologic treatment choices. Prenatal factors for increased risk of asthma could include maternal diet and the maternal microbiome. Evidence also suggests that postnatal microbial exposures and colonization contribute to the risk of allergic diseases and asthma. After confirming the diagnosis, asthma management in children centers on 3 broad areas: pharmacologic treatment, treatment of underlying comorbidities, and education of the patient and caregivers on the importance of adherence and device technique. Moreover, social determinants of health significantly impact on symptom burden and treatment response.
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17
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Chung HL. Diagnosis and management of asthma in infants and preschoolers. Clin Exp Pediatr 2022; 65:574-584. [PMID: 35436814 PMCID: PMC9742764 DOI: 10.3345/cep.2021.01746] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/31/2022] [Indexed: 01/06/2023] Open
Abstract
Asthma is one of the most common chronic disease affecting children, and it often starts in infancy and preschool years. In previous birth cohorts, frequent wheezing in early life was associated with the development of asthma in later childhood and reduced lung function persisting into adulthood. Preschool wheezing is considered an umbrella term for distinctive diseases with different clinical features (phenotypes), each of which may be related to different underlying pathophysiologic mechanisms (endotypes). The classification of phenotypes of early wheezing is needed to identify children at high risk for developing asthma later who might benefit from early intervention. However, diagnosis of asthma in infants and preschoolers is particularly difficult because objective lung function tests cannot be performed and definitive biomarkers are lacking. Moreover, management of early asthma is challenging because of its different phenotypic presentations. Many prediction models and asthma guidelines have been developed to provide useful information for physicians to assess young children with recurrent wheezing and manage them appropriately. Many recent studies have investigated the application of personalized medicine for early asthma by identifying specific phenotypes and biomarkers. Further researches, including genetic and molecular studies, are needed to establish a clear definition of asthma and develop more targeted therapeutic approaches in this age group.
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Affiliation(s)
- Hai Lee Chung
- Department of Pediatrics, School of Medicine, Daegu Catholic University, Daegu, Korea
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18
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Asthma and Wheeze Severity and the Oropharyngeal Microbiota in Children and Adolescents. Ann Am Thorac Soc 2022; 19:2031-2043. [PMID: 35904980 DOI: 10.1513/annalsats.202110-1152oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Rationale: There is a major unmet need for improving the care of children and adolescents with severe asthma and wheeze. Identifying factors contributing to disease severity may lead to improved diagnostics, biomarkers, or therapies. The airway microbiota may be such a key factor. Objectives: To compare the oropharyngeal airway microbiota of children and adolescents with severe and mild/moderate asthma/wheeze. Methods: Oropharyngeal swab samples from school-age and preschool children in the European U-BIOPRED (Unbiased BIOmarkers in the PREDiction of respiratory disease outcomes) multicenter study of severe asthma, all receiving severity-appropriate treatment, were examined using 16S ribosomal RNA gene sequencing. Bacterial taxa were defined as amplicon sequence variants. Results: We analyzed 241 samples from four cohorts: A) 86 school-age children with severe asthma; B) 39 school-age children with mild/moderate asthma; C) 65 preschool children with severe wheeze; and D) 51 preschool children with mild/moderate wheeze. The most common bacteria were Streptococcus (mean relative abundance, 33.5%), Veillonella (10.3%), Haemophilus (7.0%), Prevotella (5.9%), and Rothia (5.5%). Age group (school-age vs. preschool) was associated with the microbiota in β-diversity analysis (F = 3.32, P = 0.011) and in a differential abundance analysis (28 significant amplicon sequence variants). Among all children, we found no significant difference in the microbiota between children with severe and mild/moderate asthma/wheeze in univariable β-diversity analysis (F = 1.99, P = 0.08, N = 241), but a significant difference in a multivariable model (F = 2.66, P = 0.035), including the number of exacerbations in the previous year. Age was also significant when expressed as a microbial maturity score (Spearman Rho, 0.39; P = 4.6 × 10-10); however, this score was not associated with asthma/wheeze severity. Conclusions: There was a modest difference in the oropharyngeal airway microbiota between children with severe and mild/moderate asthma/wheeze across all children but not in individual age groups, and a strong association between the microbiota and age. This suggests the oropharyngeal airway microbiota as an interesting entity in studying asthma severity, but probably without the strength to serve as a biomarker for targeted intervention.
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19
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Grandinetti R, Fainardi V, Caffarelli C, Capoferri G, Lazzara A, Tornesello M, Meoli A, Bergamini BM, Bertelli L, Biserna L, Bottau P, Corinaldesi E, De Paulis N, Dondi A, Guidi B, Lombardi F, Magistrali MS, Marastoni E, Pastorelli S, Piccorossi A, Poloni M, Tagliati S, Vaienti F, Gregori G, Sacchetti R, Mari S, Musetti M, Antodaro F, Bergomi A, Reggiani L, Caramelli F, De Fanti A, Marchetti F, Ricci G, Esposito S. Risk Factors Affecting Development and Persistence of Preschool Wheezing: Consensus Document of the Emilia-Romagna Asthma (ERA) Study Group. J Clin Med 2022; 11:6558. [PMID: 36362786 PMCID: PMC9655250 DOI: 10.3390/jcm11216558] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 07/30/2023] Open
Abstract
Wheezing at preschool age (i.e., before the age of six) is common, occurring in about 30% of children before the age of three. In terms of health care burden, preschool children with wheeze show double the rate of access to the emergency department and five times the rate of hospital admissions compared with school-age asthmatics. The consensus document aims to analyse the underlying mechanisms involved in the pathogenesis of preschool wheezing and define the risk factors (i.e., allergy, atopy, infection, bronchiolitis, genetics, indoor and outdoor pollution, tobacco smoke exposure, obesity, prematurity) and the protective factors (i.e., probiotics, breastfeeding, vitamin D, influenza vaccination, non-specific immunomodulators) associated with the development of the disease in the young child. A multidisciplinary panel of experts from the Emilia-Romagna Region, Italy, addressed twelve key questions regarding managing preschool wheezing. Clinical questions have been formulated by the expert panel using the PICO format (Patients, Intervention, Comparison, Outcomes). Systematic reviews have been conducted on PubMed to answer these specific questions and formulate recommendations. The GRADE approach has been used for each selected paper to assess the quality of the evidence and the degree of recommendations. Based on a panel of experts and extensive updated literature, this consensus document provides insight into the pathogenesis, risk and protective factors associated with the development and persistence of preschool wheezing. Undoubtedly, more research is needed to improve our understanding of the disease and confirm the associations between certain factors and the risk of wheezing in early life. In addition, preventive strategies must be promoted to avoid children's exposure to risk factors that may permanently affect respiratory health.
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Affiliation(s)
- Roberto Grandinetti
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Valentina Fainardi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Carlo Caffarelli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Gaia Capoferri
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Angela Lazzara
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Marco Tornesello
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Aniello Meoli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Barbara Maria Bergamini
- Paediatric Unit, Department of Medical and Surgical Sciences of Mothers, Children and Adults, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Luca Bertelli
- Pediatric Clinic, Scientific Institute for Research and Healthcare (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Loretta Biserna
- Paediatrics and Neonatology Unit, Ravenna Hospital, AUSL Romagna, 48121 Ravenna, Italy
| | - Paolo Bottau
- Paediatrics Unit, Imola Hospital, 40026 Imola, Italy
| | | | - Nicoletta De Paulis
- Paediatrics and Neonatology Unit, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy
| | - Arianna Dondi
- Pediatric Clinic, Scientific Institute for Research and Healthcare (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Battista Guidi
- Hospital and Territorial Paediatrics Unit, Pavullo, 41026 Pavullo Nel Frignano, Italy
| | | | - Maria Sole Magistrali
- Paediatrics and Neonatology Unit, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy
| | - Elisabetta Marastoni
- Paediatrics Unit, Santa Maria Nuova Hospital, AUSL-IRCCS of Reggio Emilia, 42123 Reggio Emilia, Italy
| | | | - Alessandra Piccorossi
- Paediatrics and Paediatric Intensive Care Unit, Cesena Hospital, AUSL Romagna, 47521 Cesena, Italy
| | - Maurizio Poloni
- Paediatrics Unit, Rimini Hospital, AUSL Romagna, 47921 Rimini, Italy
| | | | - Francesca Vaienti
- Paediatrics Unit, G.B. Morgagni—L. Pierantoni Hospital, AUSL Romagna, 47121 Forlì, Italy
| | - Giuseppe Gregori
- Primary Care Pediatricians, AUSL Piacenza, 29121 Piacenza, Italy
| | | | - Sandra Mari
- Primary Care Pediatricians, AUSL Parma, 43126 Parma, Italy
| | | | | | - Andrea Bergomi
- Primary Care Pediatricians, AUSL Modena, 41125 Modena, Italy
| | | | - Fabio Caramelli
- Pediatric Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Alessandro De Fanti
- Paediatrics Unit, Santa Maria Nuova Hospital, AUSL-IRCCS of Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Federico Marchetti
- Paediatrics and Neonatology Unit, Ravenna Hospital, AUSL Romagna, 48121 Ravenna, Italy
| | - Giampaolo Ricci
- Pediatric Clinic, Scientific Institute for Research and Healthcare (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
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20
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Viral Infections and Wheezing in Preschool Children. Immunol Allergy Clin North Am 2022; 42:727-741. [DOI: 10.1016/j.iac.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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21
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Management of Preschool Wheezing: Guideline from the Emilia-Romagna Asthma (ERA) Study Group. J Clin Med 2022; 11:jcm11164763. [PMID: 36013002 PMCID: PMC9409690 DOI: 10.3390/jcm11164763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 12/20/2022] Open
Abstract
Preschool wheezing should be considered an umbrella term for distinctive diseases with different observable and measurable phenotypes. Despite many efforts, there is a large gap in knowledge regarding management of preschool wheezing. In order to fill this lack of knowledge, the aim of these guidelines was to define management of wheezing disorders in preschool children (aged up to 5 years). A multidisciplinary panel of experts of the Emilia-Romagna Region, Italy, addressed twelve different key questions regarding the management of preschool wheezing. Clinical questions have been formulated by the expert panel using the PICO format (Patients, Intervention, Comparison, Outcomes) and systematic reviews have been conducted on PubMed to answer these specific questions, with the aim of formulating recommendations. The GRADE approach has been used for each selected paper, to assess the quality of the evidence and the degree of recommendations. These guidelines represent, in our opinion, the most complete and up-to-date collection of recommendations on preschool wheezing to guide pediatricians in the management of their patients, standardizing approaches. Undoubtedly, more research is needed to find objective biomarkers and understand underlying mechanisms to assess phenotype and endotype and to personalize targeted treatment.
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22
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Stick SM, Foti A, Ware RS, Tiddens HAWM, Clements BS, Armstrong DS, Selvadurai H, Tai A, Cooper PJ, Byrnes CA, Belessis Y, Wainwright C, Jaffe A, Robinson P, Saiman L, Sly PD. The effect of azithromycin on structural lung disease in infants with cystic fibrosis (COMBAT CF): a phase 3, randomised, double-blind, placebo-controlled clinical trial. THE LANCET RESPIRATORY MEDICINE 2022; 10:776-784. [DOI: 10.1016/s2213-2600(22)00165-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/08/2022] [Accepted: 04/10/2022] [Indexed: 12/28/2022]
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23
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Kahan BC, White IR, Hooper R, Eldridge S. Re-randomisation trials in multi-episode settings: Estimands and independence estimators. Stat Methods Med Res 2022; 31:1342-1354. [PMID: 35422159 PMCID: PMC9251752 DOI: 10.1177/09622802221094140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Often patients may require treatment on multiple occasions. The re-randomisation design can be used in such multi-episode settings, as it allows patients to be re-enrolled and re-randomised for each new treatment episode they experience. We propose a set of estimands that can be used in multi-episode settings, focusing on issues unique to multi-episode settings, namely how each episode should be weighted, how the patient's treatment history in previous episodes should be handled, and whether episode-specific effects or average effects across all episodes should be used. We then propose independence estimators for each estimand, and show the manner in which many re-randomisation trials have been analysed in the past (a simple comparison between all intervention episodes vs. all control episodes) corresponds to a per-episode added-benefit estimand, that is, the average effect of the intervention across all episodes, over and above any benefit conferred from the intervention in previous episodes. We show this estimator is generally unbiased, and describe when other estimators will be unbiased. We conclude that (i) consideration of these estimands can help guide the choice of which analysis method is most appropriate; and (ii) the re-randomisation design with an independence estimator can be a useful approach in multi-episode settings.
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Affiliation(s)
- Brennan C Kahan
- Pragmatic Clinical Trials Unit, Queen Mary University of
London, London, UK
- MRC Clinical Trials Unit at
UCL, London, UK
| | | | - Richard Hooper
- Pragmatic Clinical Trials Unit, Queen Mary University of
London, London, UK
| | - Sandra Eldridge
- Pragmatic Clinical Trials Unit, Queen Mary University of
London, London, UK
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24
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Ghimire JJ, Jat KR, Sankar J, Lodha R, Iyer VK, Gautam H, Sood S, Kabra SK. Azithromycin for Poorly Controlled Asthma in Children: A Randomized Controlled Trial. Chest 2022; 161:1456-1464. [PMID: 35202621 DOI: 10.1016/j.chest.2022.02.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 02/04/2022] [Accepted: 02/12/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Azithromycin has immunomodulatory actions, and its beneficial effects have been demonstrated in asthmatic adults. Data on children are limited. RESEARCH QUESTION Does the addition of oral azithromycin to standard therapy in children with poorly controlled asthma improve asthma control compared with standard treatment alone? STUDY DESIGN AND METHODS This open-label randomized controlled trial included children (5-15 years of age) with poorly controlled asthma defined by Asthma Control Test (ACT) and Childhood Asthma Control Test (CACT) score of ≤ 19. They were randomized to receive azithromycin (10 mg/kg) three times weekly for 3 months along with standard treatment or standard treatment alone. The primary outcome was the ACT and CACT scores at 3 months. Secondary outcomes were asthma control according to Global Initiative for Asthma (GINA) guidelines, the number of exacerbations, change in spirometry parameters, change in fractional exhaled nitric oxide (Feno) level, positive throat swab results, and side effects. RESULTS The trial included 120 children (89 boys; 60 in each group). The mean ± SD age was 9.9 ± 3 years. The baseline parameters were similar between the groups. Mean ± SD ACT and CACT scores (available for 115 children) at 3 months of intervention were 21.71 ± 2.17 vs 18.33 ± 2.19 (P < .001) in the azithromycin and control groups, respectively. The numbers of children with well-controlled asthma according to GINA guidelines were 41 of 56 vs 10 of 56 in the azithromycin and control groups, respectively (P < .001). The median number of exacerbations requiring emergency visit and steroid use were fewer in the azithromycin group: 0 (interquartile range [IQR], 3) vs 1 [IQR, 6]; P < .001). No difference was found in Feno level, spirometry parameters, positive throat swab results, and adverse effects between the groups. INTERPRETATION The use of azithromycin in children with poorly controlled asthma resulted in improved asthma control and reduced exacerbations. TRIAL REGISTRY Clinical Trials Registry - India; No.: CTRI/2019/06/019727; URL: www.ctri.nic.in.
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Affiliation(s)
- Jagat Jeevan Ghimire
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, New Delhi, India
| | - Kana Ram Jat
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, New Delhi, India.
| | - Jhuma Sankar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, New Delhi, India
| | - Rakesh Lodha
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, New Delhi, India
| | - Venkat K Iyer
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Hitender Gautam
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Seema Sood
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - S K Kabra
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, New Delhi, India
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25
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Pinto JM, Wagle S, Navallo LJ, Petrova A. Risk Factors and Outcomes Associated With Antibiotic Therapy in Children Hospitalized With Asthma Exacerbation. J Pediatr Pharmacol Ther 2022; 27:366-372. [DOI: 10.5863/1551-6776-27.4.366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 10/29/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
Despite lack of benefit, antibiotics are overused in management of asthma exacerbation in children. In this study, data from a single children's hospital were analyzed to identify factors and outcomes associated with antibiotic use in children hospitalized with asthma.
METHODS
The study population was identified by using administrative data from 2012 to 2015, with subsequent verification of asthma. We analyzed factors associated with antibiotic use (demographic, seasonal, clinical) and outcome (length of stay [LOS]) with respect to: 1) disposition to pediatric floor (PF) or pediatric intensive care unit (PICU); and 2) evidence of coexisting bacterial infection and/or fever. Statistical analysis included univariate and controlled regression models. Data are presented as median and IQR for continuous variables and OR and regression coefficient (β) with 95% CIs for regression analyses.
RESULTS
Of 600 patients, 28.8% were admitted to PICU, 14.8% had verified bacterial infection, and 53.8% received antibiotic, mainly azithromycin. Nearly all PICU patients were treated with antibiotic, irrespective of coexisting bacterial infection or fever. Among PF patients, nearly 30% without bacterial infection or fever and 40% with fever alone received antimicrobials. Overall risk for antibiotic treatment was associated with older age, female sex, desaturation events, oxygen supplementation, and PICU admission. Additionally, antibiotic treatment was associated with 13- to 19-hour increased LOS for PF patients without bacterial infection and/or fever.
CONCLUSIONS
Almost half of pediatric patients admitted with asthma exacerbation received antibiotic therapy with no clear indication, which was associated with prolonged LOS.
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Affiliation(s)
- Jamie M. Pinto
- Department of Pediatrics (JMP, SW, LJN), Jersey Shore University Medical Center, Neptune, NJ
| | - Sarita Wagle
- Department of Pediatrics (JMP, SW, LJN), Jersey Shore University Medical Center, Neptune, NJ
| | - Lauren J. Navallo
- Department of Pediatrics (JMP, SW, LJN), Jersey Shore University Medical Center, Neptune, NJ
| | - Anna Petrova
- Department of Pediatrics (AP), Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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Kyvsgaard JN, Ralfkiaer U, Følsgaard N, Jensen TM, Hesselberg LM, Schoos AMM, Bønnelykke K, Bisgaard H, Stokholm J, Chawes B. Azithromycin and high-dose vitamin D for treatment and prevention of asthma-like episodes in hospitalised preschool children: study protocol for a combined double-blind randomised controlled trial. BMJ Open 2022; 12:e054762. [PMID: 35418427 PMCID: PMC9014042 DOI: 10.1136/bmjopen-2021-054762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Previous randomised controlled trials (RCTs) suggest antibiotics for treating episodes of asthma-like symptoms in preschool children. Further, high-dose vitamin D supplementation has been shown to reduce the rate of asthma exacerbations among adults with asthma, while RCTs in preschool children are lacking. The aims of this combined RCT are to evaluate treatment effect of azithromycin on episode duration and the preventive effect of high-dose vitamin D supplementation on subsequent episodes of asthma-like symptoms among hospitalised preschoolers. METHODS AND ANALYSIS Eligible participants, 1-5 years old children with a history of recurrent asthma-like symptoms hospitalised due to an acute episode, will be randomly allocated 1:1 to azithromycin (10 mg/kg/day) or placebo for 3 days (n=250). Further, independent of the azithromycin intervention participants will be randomly allocated 1:1 to high-dose vitamin D (2000 IU/day+ standard dose 400 IU/day) or standard dose (400 IU/day) for 1 year (n=320). Participants are monitored with electronic diaries for asthma-like symptoms, asthma medication, adverse events and sick-leave. The primary outcome for the azithromycin intervention is duration of asthma-like symptoms after treatment. Secondary outcomes include duration of hospitalisation and antiasthmatic treatment. The primary outcome for the vitamin D intervention is the number of exacerbations during the treatment period. Secondary outcomes include time to first exacerbation, symptom burden, asthma medication and safety. ETHICS AND DISSEMINATION The RCTs are approved by the Danish local ethical committee and conducted in accordance with the guiding principles of the Declaration of Helsinki. The Danish Medicines Agency has approved the azithromycin RCT, which is monitored by the local Unit for Good Clinical Practice. The vitamin D RCT has been reviewed and is not considered a medical intervention. Results will be published in peer-reviewed journals and presented at international conferences. TRIAL REGISTRATION NUMBERS NCT05028153, NCT05043116.
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Affiliation(s)
- Julie Nyholm Kyvsgaard
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
- Department of Peadiatrics, Slagelse Hospital, Slagelse, Denmark
| | - Ulrik Ralfkiaer
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Nilofar Følsgaard
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Trine Mølbæk Jensen
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
- Department of Peadiatrics, Slagelse Hospital, Slagelse, Denmark
| | - Laura Marie Hesselberg
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Ann-Marie M Schoos
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
- Department of Peadiatrics, Slagelse Hospital, Slagelse, Denmark
| | - Klaus Bønnelykke
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Hans Bisgaard
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Jakob Stokholm
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
- Department of Peadiatrics, Slagelse Hospital, Slagelse, Denmark
| | - Bo Chawes
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
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Trischler J, von Blumroeder M, Donath H, Kluge S, Hutter M, Dreßler M, Zielen S. Antibiotic Use in Paediatric Patients Hospitalized with Acute Severe Asthma. KLINISCHE PADIATRIE 2022; 234:277-283. [PMID: 35315003 DOI: 10.1055/a-1712-4225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Antibiotic use during asthma exacerbations in paediatric patients is not routinely recommended but common practise in out-patient and in-patient settings. Objective of this study was to analyse frequency of antibiotic use during acute severe asthma exacerbations, antibiotic classes utilized and clinical decision-making. METHODS All in-patient admissions over 10 years in a single German Children's University hospital due to acute severe asthma were included in this retrospective analysis. Age, length of stay, oxygen supplementation, treatment, laboratory parameters and chest x-rays of all patients ranging from 1 to 17 years were analysed. RESULTS 580 hospital admissions were included in this study. Overall antibiotic use was high but decreased with age (1-5 years 69,6%, 6-11 years 57,6% and 12-17 years 39,7%, p<0.001). Analysis of antibiotic treatment without clear indication showed a consistently lower treatment rate of 28.3%, with macrolides being the most common antibiotic class. Younger age significantly decreased, whereas, increase of CrP value, use of oxygen supplementation and concomitant fever all significantly increased the odds ratio (OR 0.967; 4.366, 2.472 and 2.011 respectively) of receiving antibiotic treatment without clear indication. CONCLUSION Antibiotic treatment without clear indication during acute severe asthma is common in this German single-centre cohort. Clinical parameters of more severe disease affect clinician's decision to administer antibiotics despite evidence of bacterial infection or improved outcome.
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Affiliation(s)
- Jordis Trischler
- Division of Allergy, Pulmonology and Cystic fibrosis, Department for Children and Adolescents, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Malin von Blumroeder
- Division of Allergy, Pulmonology and Cystic fibrosis, Department for Children and Adolescents, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Helena Donath
- Division of Allergy, Pulmonology and Cystic fibrosis, Department for Children and Adolescents, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Sven Kluge
- Division of Allergy, Pulmonology and Cystic fibrosis, Department for Children and Adolescents, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Martin Hutter
- Division of Allergy, Pulmonology and Cystic fibrosis, Department for Children and Adolescents, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Melanie Dreßler
- Division of Allergy, Pulmonology and Cystic fibrosis, Department for Children and Adolescents, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Stefan Zielen
- Division of Allergy, Pulmonology and Cystic fibrosis, Department for Children and Adolescents, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
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Jackson DJ, Gern JE. Rhinovirus Infections and Their Roles in Asthma: Etiology and Exacerbations. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:673-681. [PMID: 35074599 DOI: 10.1016/j.jaip.2022.01.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/06/2022] [Accepted: 01/06/2022] [Indexed: 12/17/2022]
Abstract
Rhinovirus infections can cause wheezing illnesses in all age groups. In preschool children, rhinovirus infections frequently initiate acute wheezing illnesses. Children who wheeze with rhinoviruses are at increased risk to go on to develop asthma. Once asthma is established, rhinovirus infections are potent triggers for acute airway obstruction and exacerbations in children and adults. Paradoxically, for most individuals, rhinovirus infections commonly cause cold symptoms with little or no involvement of the lower airways. This paradox has led investigators to identify specific risk factors and mechanisms for rhinovirus wheezing, and this review will outline progress in 3 main areas. First, the 3 species of rhinoviruses have different patterns of infection and virulence. Second, personal factors such as lung function and immunity influence lower respiratory outcomes of rhinovirus infection. The mucosal immune response is critical, and the quality of the interferon response and allergic inflammation interacts to determine the risk for rhinovirus wheezing. Finally, rhinovirus infections can promote pathogen-dominated airway microbiota that increase the risk for wheezing. Although specific antivirals for rhinovirus are still not available, identifying risk factors for wheezing illnesses has provided several other potential targets and strategies for reducing the risk of rhinovirus-induced wheezing and exacerbations of asthma.
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Affiliation(s)
- David J Jackson
- Guy's Severe Asthma Centre, Guy's & St Thomas' NHS Trust, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom.
| | - James E Gern
- Departments of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
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Antiviral effects of azithromycin: A narrative review. Biomed Pharmacother 2022; 147:112682. [PMID: 35131658 PMCID: PMC8813546 DOI: 10.1016/j.biopha.2022.112682] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/26/2022] [Accepted: 01/31/2022] [Indexed: 12/20/2022] Open
Abstract
Viral infections have a great impact on human health. The urgent need to find a cure against different viruses led us to investigations in a vast range of drugs. Azithromycin (AZT), classified as a macrolide, showed various effects on different known viruses such as severe acute respiratory syndrome coronavirus (SARS-CoV), Zika, Ebola, Enterovirus (EVs) and Rhinoviruses (RVs), and Influenza A previously; namely, these viruses, which caused global concerns, are considered as targets for AZT different actions. Due to AZT background in the treatment of known viral infections mentioned above (which is described in this study), in the early stages of COVID-19 (a new zoonotic disease caused by a novel coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)) development, AZT drew attention to itself due to its antiviral and immunomodulatory effects as a valuable candidate for COVID-19 treatment. AZT usage instructions for treating different viral infections have always been under observation, and COVID-19 is no exception. There are still debates about the use of AZT in COVID-19 treatment. However, eventually, novel researches convinced WHO to announce the discontinuation of AZT use (alone or in combination with hydroxychloroquine) in treating SARS-CoV-2 infection. This research aims to study the structure of all of the viruses mentioned above and the molecular and clinical effects of AZT against the virus.
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Mikkola H, Honkila M, Tapiainen T, Jartti T. Susceptibility to rhinovirus-induced early wheezing as a risk factor for subsequent asthma development. CURRENT RESPIRATORY MEDICINE REVIEWS 2022. [DOI: 10.2174/1573398x18666220103113813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Hannele Mikkola
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Minna Honkila
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland
| | - Terhi Tapiainen
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland
| | - Tuomas Jartti
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland
- Department of Pediatrics and Adolescent Medicine, University of Turku and Turku University Hospital, Turku, Finland
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Abstract
BACKGROUND Asthma is a chronic disease in which inflammation of the airways causes symptomatic wheezing, coughing and difficult breathing. Macrolides are antibiotics with antimicrobial and anti-inflammatory activities that have been explored for the long-term control of asthma symptoms. OBJECTIVES To assess the effects of macrolides compared with placebo for managing chronic asthma. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register up to March 2021. We also manually searched bibliographies of previously published reviews and conference proceedings and contacted study authors. We included records published in any language in the search. SELECTION CRITERIA We included randomised controlled clinical trials (RCTs) involving both children and adults with asthma treated with macrolides versus placebo for four or more weeks. Primary outcomes were exacerbation requiring hospitalisation, severe exacerbations (exacerbations requiring emergency department (ED) visits or systemic steroids, or both), symptom scales, asthma control questionnaire (ACQ, score from 0 totally controlled, to 6 severely uncontrolled), Asthma Quality of Life Questionnaire (AQLQ, with score from 1 to 7 with higher scores indicating better QoL), rescue medication puffs per day, morning and evening peak expiratory flow (PEF; litres per minutes), forced expiratory volume in one second (FEV1; litres), bronchial hyperresponsiveness, and oral corticosteroid dose. Secondary outcomes were adverse events (including mortality), withdrawal, blood eosinophils, sputum eosinophils, eosinophil cationic protein (ECP) in serum, and ECP in sputum. DATA COLLECTION AND ANALYSIS Two review authors independently examined all records identified in the searches then reviewed the full text of all potentially relevant articles before extracting data in duplicate from all included studies. As per protocol, we used a fixed-effect model. We conducted a sensitivity analysis for analyses with high heterogeneity (I2 greater than 30%). GRADE was used to assess the certainty of the body of evidence. MAIN RESULTS Twenty-five studies met the inclusion criteria, randomising 1973 participants to receive macrolide or placebo for at least four weeks. Most of the included studies reported data from adults (mean age 21 to 61 years) with persistent or severe asthma, while four studies included children. All participants were recruited in outpatient settings. Inclusion criteria, interventions and outcomes were highly variable. The evidence suggests macrolides probably deliver a moderately sized reduction in exacerbations requiring hospitalisations compared to placebo (odds ratio (OR) 0.47, 95% confidence interval (CI) 0.20 to 1.12; studies = 2, participants = 529; moderate-certainty evidence). Macrolides probably reduce exacerbations requiring ED visits and/or treatment with systemic steroids (rate ratio (RaR) 0.65, 95% CI 0.53 to 0.80; studies = 4, participants = 640; moderate-certainty evidence). Macrolides may reduce symptoms (as measured on symptom scales) (standardised mean difference (SMD) -0.46, 95% CI -0.81 to -0.11; studies = 4, participants = 136 ; very low-certainty evidence). Macrolides may result in a little improvement in ACQ (SMD -0.17, 95% CI -0.31 to -0.03; studies = 5, participants = 773; low-certainty evidence). Macrolides may have little to no effect on AQLQ (mean difference (MD) 0.24, 95% CI 0.12 to 0.35; studies = 6, participants = 802; very low-certainty evidence). For both the ACQ and the AQLQ the suggested effect of macrolides versus placebo did not reach a minimal clinically important difference (MCID, 0.5 for ACQ and AQLQ) (ACQ: low-certainty evidence; AQLQ: very low-certainty evidence). Due to high heterogeneity (I2 > 30%), we conducted sensitivity analyses on the above results, which reduced the size of the suggested effects by reducing the weighting on the large, high quality studies. Macrolides may result in a small effect compared to placebo in reducing need for rescue medication (MD -0.43 puffs/day, 95% CI -0.81 to -0.04; studies = 4, participants = 314; low-certainty evidence). Macrolides may increase FEV1, but the effect is almost certainly below a level discernible to patients (MD 0.04 L, 95% CI 0 to 0.08; studies = 10, participants = 1046; low-certainty evidence). It was not possible to pool outcomes for non-specific bronchial hyperresponsiveness or lowest tolerated oral corticosteroid dose (in people requiring oral corticosteroids at baseline). There was no evidence of a difference in severe adverse events (including mortality), although less than half of the studies reported the outcome (OR 0.80, 95% CI 0.49 to 1.31; studies = 8, participants = 854; low-certainty evidence). Reporting of specific adverse effects was too inconsistent across studies for a meaningful analysis. AUTHORS' CONCLUSIONS Existing evidence suggests an effect of macrolides compared with placebo on the rate of exacerbations requiring hospitalisation. Macrolides probably reduce severe exacerbations (requiring ED visit and/or treatment with systemic steroids) and may reduce symptoms. However, we cannot rule out the possibility of other benefits or harms because the evidence is of very low quality due to heterogeneity among patients and interventions, imprecision and reporting biases. The results were mostly driven by a well-designed, well powered RCT, indicating that azithromycin may reduce exacerbation rate and improve symptom scores in severe asthma. The review highlights the need for researchers to report outcomes accurately and according to standard definitions. Macrolides can reduce exacerbation rate in people with severe asthma. Future trials could evaluate if this effect is sustained across all the severe asthma phenotypes, the comparison with newer biological drugs, whether effects persist or wane after treatment cessation and whether effects are associated with infection biomarkers.
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Affiliation(s)
- Krishna Undela
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research Guwahati, Assam, India
| | - Lucy Goldsmith
- Population Health Research Institute and Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Kayleigh M Kew
- Cochrane Editorial and Methods Department, Cochrane, London, UK
| | - Giovanni Ferrara
- Division of Pulmonary Medicine - Department of Medicine, University of Alberta and Alberta Health Services, Edmonton, Canada
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Kahan BC, White IR, Eldridge S, Hooper R. Independence estimators for re-randomisation trials in multi-episode settings: a simulation study. BMC Med Res Methodol 2021; 21:235. [PMID: 34717559 PMCID: PMC8557515 DOI: 10.1186/s12874-021-01433-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 08/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Re-randomisation trials involve re-enrolling and re-randomising patients for each new treatment episode they experience. They are often used when interest lies in the average effect of an intervention across all the episodes for which it would be used in practice. Re-randomisation trials are often analysed using independence estimators, where a working independence correlation structure is used. However, research into independence estimators in the context of re-randomisation has been limited. METHODS We performed a simulation study to evaluate the use of independence estimators in re-randomisation trials. We focussed on a continuous outcome, and the setting where treatment allocation does not affect occurrence of subsequent episodes. We evaluated different treatment effect mechanisms (e.g. by allowing the treatment effect to vary across episodes, or to become less effective on re-use, etc), and different non-enrolment mechanisms (e.g. where patients who experience a poor outcome are less likely to re-enrol for their second episode). We evaluated four different independence estimators, each corresponding to a different estimand (per-episode and per-patient approaches, and added-benefit and policy-benefit approaches). RESULTS We found that independence estimators were unbiased for the per-episode added-benefit estimand in all scenarios we considered. We found independence estimators targeting other estimands (per-patient or policy-benefit) were unbiased, except when there was differential non-enrolment between treatment groups (i.e. when different types of patients from each treatment group decide to re-enrol for subsequent episodes). We found the use of robust standard errors provided close to nominal coverage in all settings where the estimator was unbiased. CONCLUSIONS Careful choice of estimand can ensure re-randomisation trials are addressing clinically relevant questions. Independence estimators are a useful approach, and should be considered as the default estimator until the statistical properties of alternative estimators are thoroughly evaluated.
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Affiliation(s)
- Brennan C Kahan
- MRC Clinical Trials Unit at UCL, London, UK.
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK.
| | | | - Sandra Eldridge
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Richard Hooper
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
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Pijnenburg MW, Frey U, De Jongste JC, Saglani S. Childhood asthma- pathogenesis and phenotypes. Eur Respir J 2021; 59:13993003.00731-2021. [PMID: 34711541 DOI: 10.1183/13993003.00731-2021] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 10/15/2021] [Indexed: 11/05/2022]
Abstract
In the pathogenesis of asthma in children there is a pivotal role for a type 2 inflammatory response to early life exposures or events. Interactions between infections, atopy, genetic susceptibility, and environmental exposures (such as farmyard environment, air pollution, tobacco smoke exposure) influence the development of wheezing illness and the risk for progression to asthma. The immune system, lung function and the microbiome in gut and airways develop in parallel and dysbiosis of the microbiome may be a critical factor in asthma development. Increased infant weight gain and preterm birth are other risk factors for development of asthma and reduced lung function. The complex interplay between these factors explains the heterogeneity of asthma in children. Subgroups of patients can be identified as phenotypes based on clinical parameters, or endotypes, based on a specific pathophysiological mechanism. Paediatric asthma phenotypes and endotypes may ultimately help to improve diagnosis of asthma, prediction of asthma development and treatment of individual children, based on clinical, temporal, developmental or inflammatory characteristics. Unbiased, data-driven clustering, using a multidimensional or systems biology approach may be needed to better define phenotypes. The present knowledge on inflammatory phenotypes of childhood asthma has now been successfully applied in the treatment with biologicals of children with severe therapy resistant asthma, and it is to be expected that more personalized treatment options may become available.
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Affiliation(s)
- Mariëlle W Pijnenburg
- Department of Paediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Urs Frey
- University Children's Hospital Basel (UKBB), Basel, Switzerland
| | - Johan C De Jongste
- Department of Paediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College, London, UK
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Li D, Wang Y. Safety of azithromycin in pediatric infectious diseases: a clinical systematic review and meta-analysis. Transl Pediatr 2021; 10:2594-2601. [PMID: 34765483 PMCID: PMC8578745 DOI: 10.21037/tp-21-444] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/13/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Azithromycin is a second-generation macrolide antibiotic which can be used in the treatment of diseases caused by sensitive bacterial infections. This article aimed to investigate the safety of azithromycin in the treatment of infectious diseases in children by meta-analysis. METHODS PubMed, Embase, and Cochrane were selected as the search database platforms. Randomized controlled trials (RCTs) published after 2010 were searched using the following keywords: "azithromycin", "children", "adverse event", "intravenous event", and "oral". Included studies were all clinical trials of azithromycin in the treatment of pediatric diseases. After inclusion/exclusion criteria screening and bias risk assessment, data were extracted from the included studies. RevMan 5.3.5 software was used for statistical analysis to obtain both forest and funnel plots. RESULTS A total of nine articles involving 3,597 pediatric patients were included in this study. The results of meta-analysis showed that the nine articles exhibited statistical heterogeneity (I2=70%; P=0.001), and thus, a random-effects model was used. The obtained statistic was [odds ratio (OR) =0.65; 95% confidence interval (CI): (0.43, 0.97)], the statistical effect value was Z=2.10, P=0.04, and the difference was statistically significant. After excluding one article, the remaining eight articles showed homogeneity (I2=12%; P=0.34). So, using fixed-effects model analysis, the statistic was [OR =0.79; 95% CI: (0.67, 0.94)], and the effect size value was Z=2.73, P=0.006. DISCUSSION Compared with other antibiotics, the clinical safety of azithromycin is relatively good, but care should be taken when the dosage is high in treating some disease.
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Affiliation(s)
- Dongjin Li
- Neonatal/Pediatric Department, Chengdu 363 Hospital, Southwest Medical University, Chengdu, China
| | - Yajun Wang
- Department of Pediatrics, Dujiangyan People's Hospital, Dujiangyan, China
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35
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[Innovations of the GINA 2020 for Children and the Effects of COVID-19 on Children with Asthma]. ACTA ACUST UNITED AC 2021; 56:152-159. [PMID: 34421130 PMCID: PMC8371949 DOI: 10.1007/s00608-021-00908-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2021] [Indexed: 12/23/2022]
Abstract
In the years 2019-2021, the Global Initiative for Asthma (GINA) recommended some fundamental changes in the management of patients with asthma, that also affect school children and adolescents. A very significant new recommendation is that for safety, short-acting β2-agonists (SABA) should now be given in combination with inhaled corticosteroids (ICS). In adolescents, GINA steps 1 and 2 are combined and a low-dose ICS formoterol combination as needed is recommended for asthma problems. Alternatively, separation into step 1, with inhalation of SABA and an ICS as needed, and step 2, with daily inhalation of an ICS and SABA as needed, as before, is recommended. This path is suggested as the preferred treatment in children aged 6-11 years. However, these recommendations have not been adopted by all national and international guidelines, because the evidence is weak, especially in children. Tiotropium, mepolizumab, and dupilumab were added to the therapy for severe asthma.Children with asthma do not become ill with COVD-19 more often or more severely than children without asthma. Various mechanisms, such as a possible protective effect of type 2 inflammation, the antiviral and immunomodulatory effects of ICS, and the downregulation of ACE2 receptors by allergic sensitization could be responsible for this.
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Prevention and Outpatient Treatment of Asthma Exacerbations in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2567-2576. [PMID: 34246433 DOI: 10.1016/j.jaip.2021.03.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 12/17/2022]
Abstract
Acute exacerbations cause significant morbidity and mortality in children with asthma worldwide. Although exacerbations can be minor and transient, in some children they are recurrent and significantly adversely impact quality of life. Children with frequent exacerbations account for a disproportionate amount of unscheduled care in nonprimary health facilities. Frequent exacerbators are often prescribed controller medications, but poor adherence is common. Major predictors for asthma exacerbations include genetic, social, comorbid, biological, and environmental factors. Although virus infections are a key trigger for exacerbations, other environmental factors also significantly increase risk. A previous exacerbation is a major risk factor for future exacerbations and thus identifies children to target for prevention of future episodes. In this review, we discuss both modifiable and fixed factors associated with asthma exacerbations, how to assess children for risk, and which pharmacological and nonpharmacological interventions may be of benefit. Finally, we review the current evidence around treatment within the outpatient setting for an emerging exacerbation.
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Gaffin JM. Reconstructing Phenotypes in Recurrent Severe Wheeze in Young Children. Am J Respir Crit Care Med 2021; 204:495-496. [PMID: 34181864 PMCID: PMC8491251 DOI: 10.1164/rccm.202105-1294ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jonathan M Gaffin
- Boston Children's Hospital, Respiratory Diseases, Boston, Massachusetts, United States;
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Carlsson CJ, Rasmussen MA, Pedersen SB, Wang N, Stokholm J, Chawes BL, Bønnelykke K, Bisgaard H. Airway immune mediator levels during asthma-like symptoms in young children and their possible role in response to azithromycin. Allergy 2021; 76:1754-1764. [PMID: 33150590 DOI: 10.1111/all.14651] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Asthma-like symptoms in young children are orchestrated by the local airway immune response, but current knowledge largely relies on in vitro airway models. Azithromycin has been shown to reduce the duration of episodes with asthma-like symptoms, but efficacy may depend on the individual child's immune response. OBJECTIVES To investigate in vivo upper airway immune mediator levels during episodes with asthma-like symptoms in young children and their ability to predict the clinical response to azithromycin treatment. METHODS A total of 535 children aged 0-3 years from the Copenhagen Prospective Studies of Asthma in Childhood-2010 mother-child cohort were examined for immune mediator levels in samples of nasal epithelial lining fluid during episodes with asthma-like symptoms as well as in the asymptomatic state. In a sub-study, children with recurrent asthma-like symptoms were randomized to either a 3-day course of oral azithromycin (10 mg/kg; n = 32) or placebo (n = 38). In the current study, we compared the pretreatment immune mediator levels with the clinical response to treatment with azithromycin in an exploratory post hoc analysis. RESULTS The immune mediator concentrations during vs outside episodes were significantly upregulated for IFN-ɣ (ratio 1.73), TNF-α (ratio 2.05), IL-1β (ratio 1.45), IL-10 (ratio 1.97), while CCL22 (ratio 0.65) was downregulated. Low levels of TNF-α and IL-10 and high levels of CCL22 predicted better treatment response to azithromycin (P-values < .05). CONCLUSION Upper airway immune mediator levels were altered during episodes of asthma-like symptoms, and levels of TNF-α, CCL22, and IL-10 may predict the response to azithromycin treatment.
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Affiliation(s)
- Christian J. Carlsson
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
| | - Morten A. Rasmussen
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
- Department of Food Science University of Copenhagen Frederiksberg Denmark
| | - Susanne B. Pedersen
- Department of Biotechnology and Biomedicine Technical University of Denmark Lyngby Denmark
| | - Ni Wang
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
| | - Jakob Stokholm
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
| | - Bo L. Chawes
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
| | - Klaus Bønnelykke
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
| | - Hans Bisgaard
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
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Nino G, Rodriguez-Martinez CE, Gutierrez MJ. Early Microbial-Immune Interactions and Innate Immune Training of the Respiratory System during Health and Disease. CHILDREN-BASEL 2021; 8:children8050413. [PMID: 34069319 PMCID: PMC8158711 DOI: 10.3390/children8050413] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/12/2021] [Accepted: 05/16/2021] [Indexed: 12/24/2022]
Abstract
Over the past two decades, several studies have positioned early-life microbial exposure as a key factor for protection or susceptibility to respiratory diseases. Birth cohorts have identified a strong link between neonatal bacterial colonization of the nasal airway and gut with the risk for respiratory infections and childhood asthma. Translational studies have provided companion mechanistic insights on how viral and bacterial exposures in early life affect immune development at the respiratory mucosal barrier. In this review, we summarize and discuss our current understanding of how early microbial–immune interactions occur during infancy, with a particular focus on the emergent paradigm of “innate immune training”. Future human-based studies including newborns and infants are needed to inform the timing and key pathways implicated in the development, maturation, and innate training of the airway immune response, and how early microbiota and virus exposures modulate these processes in the respiratory system during health and disease.
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Affiliation(s)
- Gustavo Nino
- Division of Pediatric Pulmonary and Sleep Medicine, Children’s National Hospital, George Washington University, Washington, DC 20052, USA
- Correspondence:
| | - Carlos E. Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota 111321, Colombia;
- Department of Pediatric Pulmonology, School of Medicine, Universidad El Bosque, Bogota 110121, Colombia
| | - Maria J. Gutierrez
- Division of Pediatric Allergy and Immunology, Johns Hopkins University, Baltimore, MD 21218, USA;
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Bacharier LB. Azithromycin during Wheezing Illnesses among Preschool Children: Does the Airway Microbiota Provide Insights into Mechanism? Am J Respir Crit Care Med 2021; 204:115-116. [PMID: 33891824 PMCID: PMC8650781 DOI: 10.1164/rccm.202104-0842ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Leonard B Bacharier
- Division of Pediatric Allergy, Immunology and Pulmonary Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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41
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Bonner K, Scotney E, Saglani S. Factors and mechanisms contributing to the development of preschool wheezing disorders. Expert Rev Respir Med 2021; 15:745-760. [PMID: 33881953 DOI: 10.1080/17476348.2021.1913057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Half of all children will experience an episode of wheezing by their sixth birthday and acute episodes of wheezing in preschool children account for the majority of all childhood hospital admissions for wheeze. Recurrent preschool wheezing associates with early loss of lung function and a life-long impact on lung health. AREAS COVERED We reviewed the literature on PubMed from August 2010-2020 focussing on factors associated with wheeze inception and persistence, paying specific attention to mechanistic studies that have investigated the impact of early life exposures in shaping immune responses in children with underlying susceptibility to wheezing. In particular, the role of early allergen sensitization, respiratory infections, and the impact of the environment on shaping the airway microbiome and resulting immune responses are discussed. EXPERT OPINION There is an abundance of associative data showing the role of in utero and postnatal factors influencing wheeze onset and persistence. However, mechanistic and stratified, biomarker-based interventional studies that confirm these associations are now needed if we are to impact the significant healthcare burden resulting from preschool wheezing disorders.
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Affiliation(s)
- Katie Bonner
- Inflammation, Repair & Development Section, National Heart & Lung Institute, Imperial College London, London, UK.,Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Elizabeth Scotney
- Inflammation, Repair & Development Section, National Heart & Lung Institute, Imperial College London, London, UK.,Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Sejal Saglani
- Inflammation, Repair & Development Section, National Heart & Lung Institute, Imperial College London, London, UK.,Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
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Thorsen J, Stokholm J, Rasmussen MA, Mortensen MS, Brejnrod AD, Hjelmsø M, Shah S, Chawes B, Bønnelykke K, Sørensen SJ, Bisgaard H. The Airway Microbiota Modulates Effect of Azithromycin Treatment for Episodes of Recurrent Asthma-like Symptoms in Preschool Children: A Randomized Clinical Trial. Am J Respir Crit Care Med 2021; 204:149-158. [PMID: 33730519 DOI: 10.1164/rccm.202008-3226oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Childhood asthma is often preceded by recurrent episodes of asthma-like symptoms, which can be triggered by both viral and bacterial agents. Recent randomized controlled trials have shown that azithromycin treatment reduces episode duration and severity through yet undefined mechanisms. Objectives: To study the influence of the airway microbiota on the effect of azithromycin treatment during acute episodes of asthma-like symptoms. Methods: Children from the COPSAC2010 (Copenhagen Prospective Studies on Asthma in Childhood 2010) cohort with recurrent asthma-like symptoms aged 12-36 months were randomized during acute episodes to azithromycin or placebo as previously reported. Before randomization, hypopharyngeal aspirates were collected and examined by 16S ribosomal RNA gene amplicon sequencing. Measurements and Main Results: In 139 airway samples from 68 children, episode duration after randomization was associated with microbiota richness (7.5% increased duration per 10 additional operational taxonomic units [OTUs]; 95% confidence interval, 1-14%; P = 0.025), with 15 individual OTUs (including several Neisseria and Veillonella), and with microbial pneumotypes defined from weighted UniFrac distances (longest durations in a Neisseria-dominated pneumotype). Microbiota richness before treatment increased the effect of azithromycin by 10% per 10 additional OTUs, and more OTUs were positively versus negatively associated with an increased azithromycin effect (82 vs. 58; P = 0.0032). Furthermore, effect modification of azithromycin was found for five individual OTUs (three OTUs increased and two OTUs decreased the effect; q < 0.05). Conclusions: The airway microbiota in acute episodes of asthma-like symptoms is associated with episode duration and modifies the effect of azithromycin treatment of the episodes in preschool children with recurrent asthma-like symptoms. Clinical trial registered with www.clinicaltrials.gov (NCT01233297).
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Affiliation(s)
- Jonathan Thorsen
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital.,Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, and
| | - Jakob Stokholm
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital.,Department of Food Science, Faculty of Science, and.,Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
| | - Morten Arendt Rasmussen
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital.,Department of Food Science, Faculty of Science, and
| | - Martin Steen Mortensen
- Section for Microbiology, Department of Biology, Faculty of Science, University of Copenhagen, Copenhagen, Denmark; and
| | - Asker Daniel Brejnrod
- Section for Microbiology, Department of Biology, Faculty of Science, University of Copenhagen, Copenhagen, Denmark; and
| | - Mathis Hjelmsø
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital
| | - Shiraz Shah
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital
| | - Bo Chawes
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital
| | - Klaus Bønnelykke
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital
| | - Søren Johannes Sørensen
- Section for Microbiology, Department of Biology, Faculty of Science, University of Copenhagen, Copenhagen, Denmark; and
| | - Hans Bisgaard
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital
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Which Wheezing Preschoolers Should be Treated for Asthma? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2611-2618. [PMID: 33677078 DOI: 10.1016/j.jaip.2021.02.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/05/2021] [Accepted: 02/20/2021] [Indexed: 11/23/2022]
Abstract
Wheezing disorders in children younger than 5 years are common, but lack of clarity remains about which children should be treated to prevent symptoms and acute episodes. The aim of this review was to discuss a practical approach to deciding which children younger than 5 years with asthma should be treated, and if so, with which strategy. The importance of having a clear definition of "asthma" for this age group, determined by a collection of presenting respiratory symptoms, without assumptions about underlying mechanisms is addressed. Subsequent consideration should be given to timing, severity, and frequency of symptoms, together with assessment of objective biomarkers, including aeroallergen sensitization and blood eosinophils, to inform whether or not a preschooler with recurrent wheezing requires treatment. Numerous unanswered questions remain about the optimal management of nonallergic preschool wheezing and asthma, and areas of specific unmet need and future directions for research are highlighted.
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Lipsett SC, Hall M, Ambroggio L, Hersh AL, Shah SS, Brogan TV, Gerber JS, Williams DJ, Grijalva CG, Blaschke AJ, Neuman MI. Antibiotic Choice and Clinical Outcomes in Ambulatory Children with Community-Acquired Pneumonia. J Pediatr 2021; 229:207-215.e1. [PMID: 33045236 PMCID: PMC7856045 DOI: 10.1016/j.jpeds.2020.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/09/2020] [Accepted: 10/05/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To describe antibiotic prescribing patterns in ambulatory children with community-acquired pneumonia and to assess the relationship between antibiotic selection and clinical outcomes. STUDY DESIGN This was a retrospective cohort study of ambulatory Medicaid-enrolled children 0-18 years of age diagnosed with community-acquired pneumonia from 2010 to 2016. The exposure was antibiotic class: narrow-spectrum (aminopenicillins), broad-spectrum (amoxicillin/clavulanate and cephalosporins), macrolide monotherapy, macrolides with narrow-spectrum antibiotics, or macrolides with broad-spectrum antibiotics. The associations between antibiotic selection and the outcomes of subsequent hospitalization and development of severe pneumonia (chest drainage procedure, intensive care admission, mechanical ventilation) were assessed, controlling for measures of illness severity. RESULTS Among 252 177 outpatient pneumonia visits, macrolide monotherapy was used in 43.2%, narrow-spectrum antibiotics in 26.1%, and broad-spectrum antibiotics in 24.7%. A total of 1488 children (0.59%) were subsequently hospitalized and 117 (0.05%) developed severe pneumonia. Compared with children receiving narrow-spectrum antibiotics, the odds of subsequent hospitalization were higher in children receiving broad-spectrum antibiotics (aOR, 1.34; 95% CI, 1.17-1.52) and lower in children receiving macrolide monotherapy (aOR, 0.64; 95% CI, 0.55-0.73) and macrolides with narrow-spectrum antibiotics (aOR, 0.62; 95% CI, 0.39-0.97). Children receiving macrolide monotherapy had lower odds of developing severe pneumonia than children receiving narrow-spectrum antibiotics (aOR, 0.56; 95% CI, 0.33-0.93). However, the absolute risk difference was <0.5% for all analyses. CONCLUSIONS Macrolides are the most commonly prescribed antibiotic for ambulatory children with community-acquired pneumonia. Subsequent hospitalization and severe pneumonia are rare. Future efforts should focus on reducing broad-spectrum and macrolide antibiotic prescribing.
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Affiliation(s)
- Susan C Lipsett
- Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
| | | | - Lilliam Ambroggio
- Sections of Emergency Medicine and Hospital Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Denver, CO
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medicine Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Thomas V Brogan
- Division of Critical Care, Seattle Children's Hospital, Seattle, WA; Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN
| | - Anne J Blaschke
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT
| | - Mark I Neuman
- Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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45
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Dhar R, Talwar D, Singh V, Dumra H, Rajan S, Jindal SK. Expert recommendations on the role of macrolides in chronic respiratory diseases. Lung India 2021; 38:174-182. [PMID: 33687013 PMCID: PMC8098884 DOI: 10.4103/lungindia.lungindia_498_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: India contributes to 32% of the total global disability-adjusted life years, due to chronic respiratory diseases. This has led to a high rate of health loss from these diseases. Antibiotics are commonly used in the management of respiratory disorders. With excellent tissue penetration, prolonged tissue persistence, and favorable side effect profile, macrolides are one of the best treatment options being recommended for respiratory, urogenital, dermal, and other bacterial infections. Still, there is a lack of clinical trial data on the use of macrolides in the management of respiratory chronic disease, and hence, there is a need for clinical guidance on their use in Indian setting. Methods: A systematic review of the literature was conducted on PubMed, Cochrane database, and Google Scholar. Existing guidelines, meta-analyses, systematic reviews, randomized controlled trials (RCTs), non-RCTs, landmark studies, and key-cited articles were selected. Recommendations were based on available evidence and expert panel's logical empiricism and consensus. Results and Discussion: This article discusses evidence-based and clinical practice based management of chronic respiratory conditions including chronic obstructive pulmonary disease, asthma, bronchiectasis, diffusive panbronchiolitis, and organizing pneumonia. The authors reviewed different respiratory conditions, role of macrolides in their management, adverse events and antimicrobial resistance associated with macrolides, evidence review of various clinical trials, guideline recommendations, and clinical recommendations.
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Affiliation(s)
- Raja Dhar
- Department of Pulmonology, Fortis Hospital, Kolkata, West Bengal, India
| | - Deepak Talwar
- Respiratory Center, Pulmonology and Sleep Medicine, Metro Group of Hospitals, Noida, Uttar Pradesh, India
| | | | - Harjit Dumra
- "Sparsh" Chest Diseases Center, Ahmedabad, Gujarat, India
| | - Sujeet Rajan
- Respiratory Medicine, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - S K Jindal
- Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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46
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Giemen im Vorschulalter. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-00995-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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47
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Okubo Y, Horimukai K, Michihata N, Morita K, Matsui H, Fushimi K, Yasunaga H. Recent Practice Patterns and Variations in Children Hospitalized for Asthma Exacerbation in Japan. Int Arch Allergy Immunol 2020; 181:926-933. [PMID: 33091910 DOI: 10.1159/000507857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/14/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND High antibiotic prescribing rates for adults with an asthma exacerbation have been reported in developed countries, but few studies have assessed the variation of antibiotic and adjunctive treatment in the routine care of children. OBJECTIVE We evaluated the trends in health resource utilization for children hospitalized for asthma exacerbation, ascertained the variations of practices across hospitals and geographic location, and classified these different patterns at hospital levels. METHODS Using data on Japanese children hospitalized for asthma exacerbation with no indication of bacterial infection during 2010-2018, we conducted a retrospective observational study to assess the trends in initial treatment patterns and their variations. Mixed-effect generalized linear models were used to investigate the treatment trends. Hierarchical cluster analyses were performed to classify the treatment variations across hospitals. RESULTS Overall, 54,981 children were eligible for the study. Proportions of antibiotic use decreased from 47.2% in 2010 to 26.9% in 2018. Similarly, utilization of antitussives, antihistamines, and methylxanthine showed decreasing trends over the period, whereas the use of mucolytics and ambroxol increased. These treatment variations were more considerable in hospital levels than in 47 prefecture levels. Hierarchical cluster analyses classified these patterns into 6 groups, mostly based on mediator release inhibitor, ambroxol, and antitussives. CONCLUSIONS Wide variations in antibiotics and adjunctive treatments were observed across hospital levels. Our findings support the improvement in reducing inappropriate antibiotic use and highlight the need for comparative effectiveness research of the adjunctive treatments among children hospitalized for asthma.
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Affiliation(s)
- Yusuke Okubo
- Department of Epidemiology, University of California, Fielding School of Public Health, Los Angeles, California, USA, .,Department of Social Medicine, National Center for Child Health and Development, Tokyo, Japan, .,Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan,
| | - Kenta Horimukai
- Department of Pediatrics, Jikei University Katsushika Medical Center, Tokyo, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kojiro Morita
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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48
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Poddighe D, Aljofan M. Clinical evidences on the antiviral properties of macrolide antibiotics in the COVID-19 era and beyond. ACTA ACUST UNITED AC 2020; 28:2040206620961712. [PMID: 32972196 PMCID: PMC7522830 DOI: 10.1177/2040206620961712] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Macrolides are a large group of antibiotics characterised by the presence of a macro-lactone ring of variable size. The prototype of macrolide antibiotics, erythromycin was first produced by Streptomyces and associated species more than half a century ago; other related drugs were developed. These drugs have been shown to have several pharmacological properties: in addition to their antibiotic activity, they possess some anti-inflammatory properties and have been also considered against non-bacterial infections. In this review, we analysed the available clinical evidences regarding the potential anti-viral activity of macrolides, by focusing on erythromycin, clarithromycin and azithromycin. Overall, there is no significant evidences so far that macrolides might have a direct benefit on most of viral infections considered in this review (RSV, Influenza, coronaviruses, Ebola and Zika viruses). However, their clinical benefit cannot be ruled out without further and focused clinical studies. Macrolides may improve the clinical course of viral respiratory infections somehow, at least through indirect mechanisms relying on some and variable anti-inflammatory and/or immunomodulatory effects, in addition to their well-known antibacterial activity.
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Affiliation(s)
- Dimitri Poddighe
- Department of Medicine, Nazarbayev University School of Medicine, Nur-Sultan City, Kazakhstan
| | - Mohamad Aljofan
- Department of Biomedical Sciences, Nazarbayev University School of Medicine, Nur-Sultan City, Kazakhstan
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49
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Jaggi P, Hamdy RF, Lee B, Hersh AL, Gerber JS, Sharland M, Terrill C, Newland JG. Use of Antimicrobial Agents in Hospitalized Children for Noninfectious Indications. J Pediatric Infect Dis Soc 2020; 9:490-493. [PMID: 32677678 DOI: 10.1093/jpids/piz053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 07/03/2019] [Indexed: 12/24/2022]
Abstract
In this point-prevalence study of 32 US children's hospitals, we determined that 1.7% of hospitalized children received at least 1 antimicrobial agent for a non-infection-related reason; macrolides were used most commonly. Antimicrobial stewardship efforts to understand and affect use for these reasons is an unmet need; additional research considering the individual and societal effects of these antimicrobial-prescribing practices should be undertaken.
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Affiliation(s)
- Preeti Jaggi
- Division of Infectious Diseases, Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Rana F Hamdy
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Division of Infectious Diseases, Children's National Medical Center, Washington, DC
| | - Brian Lee
- Department of Pediatrics, School of Medicine, Children's Mercy, Kansas City, Missouri
| | - Adam L Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, United Kingdom
| | - Mike Sharland
- Institute of Infection and Immunity, St George's University of London, United Kingdom
| | - Cindy Terrill
- Division of Infectious Diseases, Department of Pediatrics, Washington University St Louis, Missouri
| | - Jason G Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University St Louis, Missouri
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50
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Pijnenburg MW, Fleming L. Advances in understanding and reducing the burden of severe asthma in children. THE LANCET RESPIRATORY MEDICINE 2020; 8:1032-1044. [PMID: 32910897 DOI: 10.1016/s2213-2600(20)30399-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/10/2020] [Accepted: 08/22/2020] [Indexed: 01/16/2023]
Abstract
Severe asthma in children is rare, accounting for only a small proportion of childhood asthma. After addressing modifiable factors such as adherence to treatment, comorbidities, and adverse exposures, children whose disease is not well controlled on high doses of medication form a heterogeneous group of severe asthma phenotypes. Over the past decade, considerable advances have been made in understanding the pathophysiology of severe therapy-resistant asthma in children. However, asthma attacks and hospital admissions are frequent and mortality is still unacceptably high. Strategies to modify the natural history of asthma, prevent severe exacerbations, and prevent lung function decline are needed. Mechanistic studies have led to the development of several biologics targeting type 2 inflammation. This growing pipeline has the potential to reduce the burden of severe asthma; however, detailed assessment and characterisation of each child with seemingly severe asthma is necessary so that the most effective and appropriate management strategy can be implemented. Risk stratification, remote monitoring, and the integration of multiple data sources could help to tailor management for the individual child with severe asthma.
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Affiliation(s)
- Mariëlle W Pijnenburg
- Department of Paediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands.
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College, London, UK
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