Asthma guidelines: the Global Initiative for Asthma in relation to national guidelines

The effect of web-designed education on medication adherence, asthma control and fatigue in patients with asthma: A randomized controlled trial

AIMS

This study aimed to determine the effect of web-designed education developed for asthma patients on drug adherence, asthma control and fatigue.

METHODS

This randomized controlled trial was conducted between August 2021 and January 2022 with 200 individuals suffering from poor asthma control who participated in web-designed education. After the intervention, the asthma patients were followed up for 6 weeks to measure Medication Adherence Report Scale (MARS), Chronic Obstructive Pulmonary Disease and Asthma Fatigue Scale (CAFS), Asthma Control Test (ACT) and Inhalation Devices Usage Techniques Knowledge Test (IDUSTKT). Data were analysed in the Statistical Package for the Social Sciences program using the Chi-square test, Independent t-test, Man-Whitney U test, Wilcoxon test, Paired t-test, Greenhouse-Geisser (F) test and Linear regression.

RESULTS

The web-designed education had a statistically significant effect on the total scores of CAFS, ACT and IDUSTKT for individuals with asthma (p < 0.001). This intervention decreased fatigue levels, improved asthma control and enhanced knowledge of inhalation device usage techniques. Although there was an improvement in medication adherence, this difference was not statistically significant.

CONCLUSION

These results suggest that web-based educational programs can be an effective tool in asthma management and may improve patients' quality of life. Future research should examine the long-term effects of such educational programs and their effectiveness across different demographic groups in more detail.

Burden of Asthma Among a Sample of Primary Schoolchildren in Jordan Based on Child and Parental Report

BACKGROUND

Asthma is a major health issue with an extensive burden to family and health systems. Different measures were used previously to assess disease burden, including prevalence, school performance, parental perceptions, and cost among others.

AIM

The purpose of this study was to assess the burden of asthma among schoolchildren using parental and child reports and metered-dose inhaler (MDI) demonstration.

METHODS

A descriptive exploratory design based on parent and child self-reports was employed. Parents of children with asthma completed a questionnaire about asthma management and burden including symptoms and health services use. A sample of children with asthma completed a questionnaire measuring their perception of asthma management at school. An assessment of children's proper use of MDI inhalers was also conducted.

RESULTS

The burden of asthma was high in the current sample with the majority of children experiencing symptoms, asthma exacerbations, emergency department (ED) visits, and admission because of their asthma. The majority of participating children also performed incorrect inhaler technique, which reflects uncontrolled asthma and poor management. Parental perception of their child's health compared well with their burden of asthma.

CONCLUSION

The outcomes of this study and previous reports show an alarmingly high burden of asthma. This calls for collaboration between professionals and stakeholders with children and caregivers in planning and implementing care, including improving the school environment.

Neural signature of attention impairment in allergic asthma: an ERP study

Methods We recruited 38 participants, equally distributed into healthy and asthma groups. Behavioral, neurophysiological, and lung function assessment tools were used in this study.

Results Our behavioral data show that allergic asthma induces attention impairment. Additionally, the event-related potentials (ERP) analysis reveals that this attention deficit is associated with a disruption in cognitive processing capability in frontal brain areas. These behavioral and neurophysiological abnormalities were strongly correlated with disease severity and neuropsychiatric comorbidities of asthmatic patients.

Conclusion Together, here we propose that disrupted neurophysiological responses in frontal brain areas might lead to attention impairments in patients with allergic asthma. These findings could help characterizing the neuro-pathophysiology of cognitive disorders in allergic asthma, possibly opening the way for development of novel treatment strategies.

Allergic Airway Inflammation Emerges from Gut Inflammation and Leakage in Mouse Model of Asthma

Asthma is an allergic airway inflammatory disease characterized by type 2 immune responses. Growing evidence suggests an association between allergic airways and intestinal diseases. However, the primary site of disease origin and initial mechanisms involved in the development of allergic airway inflammation (AAI) is not yet understood. Therefore, the initial contributing organs and mechanisms involved in the development of AAI are investigated using a mouse model of asthma. This study, without a local allergen challenge into the lungs, demonstrates a significant increase in intestinal inflammation with signature type-2 mediators including IL-4, IL-13, STAT6, eosinophils, and Th2 cells. In addition, gut leakage and mRNA expressions of gut leakage markers significantly increase in the intestine. Moreover, reduced mRNA expressions of tight junction proteins are observed in gut and interestingly, in lung tissues. Furthermore, in lung tissues, an increased pulmonary barrier permeability and IL-4 and IL-13 levels associated with significant increase of lipopolysaccharide-binding protein (LBP-gut leakage marker) and eosinophils are observed. However, with local allergen challenges into the lungs, these mechanisms are further enhanced in both gut and lungs. In conclusion, the primary gut originated inflammatory responses translocates into the lungs to orchestrate AAI in a mouse model of asthma.

The Effects of Benralizumab on Lung Volumes and Airway Resistance in Severe Eosinophilic Asthma: A Real-World Study

INTRODUCTION

Add-on biological monoclonal antibodies such as benralizumab (anti-IL-5Ra) are recommended by international guidelines to reduce exacerbations in severe eosinophilic asthma (SEA). However, few studies have assessed the impact of these therapies on lung function-related outcomes. Our goal was to evaluate the effectiveness of benralizumab on lung function, including lung volumes and airway resistance, in SEA patients in Portugal.

METHODS

This was a real-world, observational, prospective, multicentric study including adult patients diagnosed with SEA (January-June 2023). Spirometry and plethysmography were performed at baseline (T0) and after six months of treatment (T6) with benralizumab to assess: total lung capacity (TLC), residual volume (RV), forced expiratory volume in one second (FEV1), forced vital capacity (FVC), mean forced expiratory flow between 25% and 75% of FVC (mFEF-25/75), intrathoracic gas volume (ITGV), and respiratory airway resistance (Raw). Descriptive statistics (with categorical variables described as frequencies and continuous values as mean and standard deviation (SD)) and paired t-test and Cohen's d effect size were calculated (analyses performed in StataCorp v.15.1; StataCorp LLC, TX, USA).

RESULTS

Overall, 30 SEA patients were evaluated, mostly women (n=18, 60.0%), with atopy (n=22, 73.3%), a mean age of 58.4 years (SD 11.7), and assisted by pulmonology (n=19, 63.3%) or immunology-allergology (n=11, 36.7%) services. Mean eosinophilia at baseline was 1103.57 cells/mcL (SD 604.88; minimum-maximum 460-2400); after the use of benralizumab, the count dropped to zero. After six months of treatment, a significant increase (p<0.0001) in FVC (15.3%), FEV1 (22.6%), and mFEF-25/75 (17.7%) were observed from baseline (Cohen's d between 0.78 and 1.11). ITGV, RV, RV/TLC, and Raw significantly decreased (p<0.0001) during the study period (-17.3%, -29.7%, -8.9%, and -100.6%, respectively) (Cohen's d between -0.79 and -1.06). No differences in TLC were obtained (p=0.173). No differences between sexes were observed for any measure. Patients with more significant eosinophilia (>900 cells/mcL count; n=15) presented better responses in FEV1 (p=0.001) and mFEF-25/75 (p=0.007).

CONCLUSIONS

A notable eosinophil depletion with add-on benralizumab led to significant improvements in SEA patients' respiratory function (static lung volumes and airway resistance) in real-world settings after six months. The significant deflating effect of benralizumab on patients' hyperinflated lungs led to enhanced expiratory flow (increased FEV1 and mFEF-25/75) and air trapping (decreased RV/TLC), suggesting this antibody improves bronchial obstruction, lung hyperinflation, and airway resistance. Further studies in a larger population are required to confirm these findings.

Asthma Phenotypes in the Era of Personalized Medicine

Asthma is a widespread disease affecting approximately 300-million people globally. This condition leads to significant morbidity, mortality, and economic strain worldwide. Recent clinical and laboratory research advancements have illuminated the immunological factors contributing to asthma. As of now, asthma is understood to be a heterogeneous disease. Personalized medicine involves categorizing asthma by its endotypes, linking observable characteristics to specific immunological mechanisms. Identifying these endotypic mechanisms is paramount in accurately profiling patients and tailoring therapeutic approaches using innovative biological agents targeting distinct immune pathways. This article presents a synopsis of the key immunological mechanisms implicated in the pathogenesis and manifestation of the disease's phenotypic traits and individualized treatments for severe asthma subtypes.

Epigenome-wide DNA methylation association study of circulating IgE levels identifies novel targets for asthma

BACKGROUND

Identifying novel epigenetic signatures associated with serum immunoglobulin E (IgE) may improve our understanding of molecular mechanisms underlying asthma and IgE-mediated diseases.

METHODS

We performed an epigenome-wide association study using whole blood from Framingham Heart Study (FHS; n = 3,471, 46% females) participants and validated results using the Childhood Asthma Management Program (CAMP; n = 674, 39% females) and the Genetic Epidemiology of Asthma in Costa Rica Study (CRA; n = 787, 41% females). Using the closest gene to each IgE-associated CpG, we highlighted biologically plausible pathways underlying IgE regulation and analyzed the transcription patterns linked to IgE-associated CpGs (expression quantitative trait methylation loci; eQTMs). Using prior UK Biobank summary data from genome-wide association studies of asthma and allergy, we performed Mendelian randomization (MR) for causal inference testing using the IgE-associated CpGs from FHS with methylation quantitative trait loci (mQTLs) as instrumental variables.

FINDINGS

We identified 490 statistically significant differentially methylated CpGs associated with IgE in FHS, of which 193 (39.3%) replicated in CAMP and CRA (FDR < 0.05). Gene ontology analysis revealed enrichment in pathways related to transcription factor binding, asthma, and other immunological processes. eQTM analysis identified 124 cis-eQTMs for 106 expressed genes (FDR < 0.05). MR in combination with drug-target analysis revealed CTSB and USP20 as putatively causal regulators of IgE levels (Bonferroni adjusted P < 7.94E-04) that can be explored as potential therapeutic targets.

INTERPRETATION

By integrating eQTM and MR analyses in general and clinical asthma populations, our findings provide a deeper understanding of the multidimensional inter-relations of DNA methylation, gene expression, and IgE levels.

FUNDING

US NIH/NHLBI grants: P01HL132825, K99HL159234. N01-HC-25195 and HHSN268201500001I.

The importance of skin prick test in differentiating cat sensitivities and allergies in children

BACKGROUND

The incidence of cat allergies in children has increased over the years. Children with cat allergies have mostly reported respiratory symptoms. The skin prick test (SPT) is the most preferred method to demonstrate sensitization to allergens. However, not all children who develop cat sensitization due to environmental exposure become allergic to cats. In our study, we aimed to determine the frequency of sensitization to cat and cat allergy, cat-related symptoms, and the cut-off value for the SPT that may indicate cat allergy.

METHODS

Patients aged 2-18 years, who applied to the Health Sciences University İzmir Dr Behçet Uz Pediatrics and Surgery Training and Research Hospital and Balıkesir University Application and Research Hospital Pediatric Allergy outpatient clinics between January 01, 2019 and December 31, 2020, were included in the study. Patients who underwent SPT and found to be sensitized to cat allergen, were evaluated retrospectively. Clinical and laboratory findings of the patients were recorded. Receiver operating characteristics (ROC) analysis was performed to determine the cut-off value for the SPT.

RESULTS

Sensitization to cat was detected in 140 (4%) out of 3499 patients who underwent SPT. The median age of the patients was 12 years (min-max: 5-18) and 67.1% were male. Eighty-eight (62.9%) patients were symptomatic upon contact with cats, predominantly with nasal symptoms. These patients had significantly larger cat SPT wheal size than asymptomatic patients. The cut-off value was determined as 5.5 mm with a sensitivity of 72.7% and a specificity of 61.5% (95% CI, 60.5%-78.4%). Symptoms resolved in about half of our patients by reducing contact with cats.

DISCUSSION

The present study is the first to report the frequency and clinical findings of cat sensitizations and allergies in Turkish children. For effective treatment, cat allergy must be diagnosed. In this regard, the use of a practical, readily accessible 5.5 mm cut-off point on the SPT may be helpful.

Cross-sectional study to describe allergic rhinitis flare-ups and associated airways phenotype in house dust mite sensitization

OBJECTIVES

To quantify and describe flare-ups of house dust mite allergic rhinitis (HDM-AR) which had occurred during the last 12 months in a population of adults and children candidate for Allergen ImmunoTherapy (AIT). Next, to identify associated clinical features.

MATERIALS AND METHODS

This was an observational, multicenter, cross-sectional study that included patients aged ≥ 5 years with HDM-AR eligible for AIT and without prior AIT for at least 12 months. Flare-ups were all period with impairment of quality of life (QoL) and requiring a change in their usual treatment. Data were collected using medical records and patient questionnaires. Variables associated with the occurrence of ≥ 2 AR flare-ups were identified.

RESULTS

1,701 patients were included (average age: 23 years, 51.5% males, 30.4% children, 17.7% adolescents and 51.9% adults). Severe and persistent AR affected 70.9% of them and 53.7% showed polysensitization. Asthma was associated with AR in 34.4% and was well-controlled in 58.5%. The occurrence of at least one AR flare-up in the year was reported by 77.7%, with an annual rate in the whole population of 2.6 ± 3.9 and a duration of 14.1 ± 17.1 days. Deeply or moderately AR-related degraded QoL was experienced by 39.5% and 64.6%, respectively. The occurrence of ≥ 2 AR flare-ups was reported by 54.5% and was associated with polysensitization, AR intermittence and severity.

CONCLUSION

AR flare-ups are frequent and impair QoL in HDM-allergic patients, suggesting that it could be considered as therapeutic targets.

Multiple overlapping risk factors for childhood wheeze among children in Benin

BACKGROUND

The African continent is currently facing an epidemiological transition characterized by a shift from communicable to non-communicable diseases. Prominent amongst the latter are allergies and asthma. In that context, wheeze has multiple potential contributory factors that could include some of the endemic helminth infections, as well as environmental exposures, such as household air pollution. We sought to determine the relative importance of these risk factors among children in Benin.

METHODS

We included 964 children aged 6-14 years living in the commune of Comé, south-west Benin. All children were participants in the longitudinal monitoring cohort of the DeWorm3 trial designed to evaluate multiple rounds of community mass treatment with albendazole for interruption of the transmission of soil transmitted helminths (STH). We administered a standard ISAAC questionnaire to determine the presence of wheeze. In addition, we assessed exposure to household air pollution and to other potential allergy-inducing factors, dietary intake and anthropometry. Using STH infection status assessed at the pretreatment baseline timepoint, we used multivariate statistical modelling, controlling for covariates, to investigate associations between wheeze and the different factors measured.

RESULTS

The prevalence of wheezing history was 5.2%, of current wheezing was 4.6% and of severe wheezing was 3.1%, while STH infections were found in 5.6% of children. These profiles did not vary as a function of either age or gender. Infection with Ascaris lumbricoides, but not hookworm species, was significantly associated with both current wheeze (adjusted Odds Ratio (aOR) = 4.3; 95% CI [1.5-12.0]) and severe wheeze (aOR = 9.2; 95% CI [3.1-27.8]). Significant positive associations with current wheeze, independent of each other and of STH infection status, were also found for (i) use of open cookstoves (aOR = 3.9; 95% CI [1.3-11.5]), (ii) use of palm cakes for fire lighting (aOR = 3.4; 95% CI [1.1-9.9]), (iii) contact with domestic animals and/or rodents (aOR = 2.5; 95% CI [1.1-6.0]), (iv) being overweight (aOR = 9.7; 95% CI [1.7-55.9]). Use of open cookstoves and being overweight were also independent risk factors for severe wheeze (aOR = 3.9; 95% CI [1.1-13.7]) and aOR = 10.3; 95% CI [1.8-60.0], respectively).

CONCLUSIONS

Children infected with A. lumbricoides appear to be at elevated risk of wheeze. Deworming may be an important intervention to reduce these symptoms. Improving cooking methods to reduce household air pollution, modifying dietary habits to avoid overweight, and keeping animals out of the house are all additional measures that could also contribute to reducing childrens' risk of wheeze. Policymakers in LMIC should consider tailoring public health measures to reflect the importance of these different risk factors.

Adherence to anti-asthma medications among adult asthmatic patients in Eastern Ethiopia: A multi-center cross-sectional study

INTRODUCTION

Adherence to anti-asthmatic medications plays a vital role in enhancing an asthma patient's quality of life and prognosis. However, in Ethiopia, the level of adherence and contributing factors were rarely studied. Therefore, this study was conducted to determine the level of adherence to anti-asthma medications and associated factors among adult asthmatic patients in Eastern Ethiopia.

METHOD

Institutional based cross-sectional study was conducted at six governmental hospitals found in Eastern Ethiopia. A total of 320 asthma patients aged 18 years and above and using asthma medicines for at least 12 months were involved. An interviewer based structured questionnaires were used to collect the data. Bivariable and multivariable logistic regression analyses were carried out using IBM SPSS version 22 (SPSS, Chicago, IL). The Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) was used to determine the strength of association between independent variables and outcome variable. Variables with a p-value of ≤ 0.05 were considered statistically significant.

RESULT

Of the 320 asthma patients that participated in the study, 109(34.1%:28.8-39.1%) of them had good adherence to anti-asthmatic medications. Being a housewife (AOR = 4.265, 95%CI: 1.333, 13.653), having good knowledge about asthma (AOR = 2.921, 95%CI (1.472, 5.795), positive attitude towards asthma (AOR = 3.129, 95%CI: 1.555, 6.293), and use of oral corticosteroid drugs (AOR = 1.967, 95%CI: 1.008, 3.841) were factors positively associated with good adherence to anti-asthmatic medications. Participants on treatment for 2-3 years (AOR = .295, 95%CI: 0.099, 0.873), and those on medication for ≥ 4 years (AOR = 0.229, 95%CI: 0.079, 0.664) were 70.5% and 77.1% times less likely to adhere to anti-asthmatic medications respectively.

CONCLUSION

The current study signified a low level of adherence to anti-asthmatic medications. Participant's characteristics and medication related factors were significantly associated with good adherence to anti-asthmatic medications. Health education and advice during follow-up for asthma patients is crucial for better adherence.

Symptom-driven inhaled corticosteroid/long-acting beta-agonist therapy for adult patients with asthma who are non-adherent to daily maintenance inhalers: a study protocol for a pragmatic randomized controlled trial

BACKGROUND

While inhaled corticosteroids (ICS) are considered the essential foundation of most asthma therapy, ICS inhaler nonadherence is a notoriously common problem and a significant cause of asthma-related morbidity. Partially acknowledging the problem of nonadherence, international organizations recently made paradigm-shifting recommendations that all patients with mild-to-moderate persistent asthma be considered for symptom-driven ICS-containing inhalers rather than relying on adherence to traditional maintenance ICS inhalers and symptom-driven short-acting beta-agonists (SABA). With this new approach, asthma patients are at least exposed to the important anti-inflammatory effects of ICS-containing inhalers when their symptom reliever inhaler is deployed due to acute symptoms.

METHODS

This study will (Part 1) complete a pragmatic randomized controlled trial to evaluate if an inhaler strategy that utilizes symptom-driven ICS inhalers is particularly beneficial in maintenance ICS inhaler non-adherent asthma patients, and (Part 2) use a dissemination and implementation (D&I) science conceptual framework to better understand patients' and providers' views of inhaler nonadherence. This study, which will have an option of taking place entirely remotely, will use a Food and Drug Administration (FDA)-approved electronic sensor (Hailie® sensor) to monitor inhaler adherence and includes semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR).

DISCUSSION

This study is assessing the problem of nonadherence using a D&I implementation science research lens while testing a new inhaler approach to potentially ameliorate the detrimental consequences of maintenance inhaler nonadherence. We hypothesize that the use of a symptom-driven ICS/LABA management strategy, as compared to traditional maintenance ICS treatment and symptom-driven SABA, will lead to improved adherence to an asthma treatment strategy, decreased asthma-related morbidity, less cumulative ICS exposure, and greater patient satisfaction with an inhaler approach.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05111262. Registered on November 8, 2021.

Iron status and its relation to lung function in pediatric asthmatics: a cross-sectional study

Background

Asthma and iron deficiency are common pediatric conditions. In addition, iron deficiency may affect spirometry results in asthmatic children. So, we aimed to assess the effect of ion status on lung function in childhood asthma.

Results

In this cross-sectional study, fifty asthmatic pediatric patients aged from 6 to 16 years presented to our institute during the period from (June 2018 to December 2018) were enrolled. Asthmatic patients were classified according to their complete blood count and iron profile into 2 groups: group 1, asthmatic children without iron deficiency anemia (IDA); and group 2, asthmatic children with IDA. All patients underwent full history taking, clinical examination, laboratory investigations, asthma control test, and pulmonary function tests (PFTs). The study showed that PFTs’ parameters (forced expiratory volume in one second (FEV1) % of predicted, FEV1/forced vital capacity, and maximal mid expiratory flow (MMEF) 25–75% of predicted) were significantly lower among asthmatics with IDA (80.62 ± 18.13, 78.36 ± 11.22, 62.35 ± 26.67) than among asthmatics without IDA (93.45 ± 15.51, 87.68 ± 10.81, 82.10 ± 24.74), respectively (p =0.012, 0.006, 0.012). Also, poorly controlled asthma was significantly higher among asthmatics with IDA (p =0.001). In addition, there was a statistically significant positive correlation between forced spirometry parameters, hemoglobin, and ferritin level (p=0.012, 0.042). Moreover, there was a significant positive correlation between hemoglobin level and MMEF 25–75% of predicted (p=0.012).

Conclusions

Lower iron status negatively affects the lung function in asthmatic children with a more obstructive pattern among asthmatics with IDA.

Capability, Opportunity, Motivation leads to adherence behaviour in people with asthma: protocol for a cross-sectional study. (Preprint)

BACKGROUND

Asthma is a common lung condition that cannot be cured, but it can usually be effectively managed using available treatments. Despite this, it is widely acknowledged that 70% of patients do not adhere to their asthma treatment. Personalizing treatment by providing the most appropriate interventions based on the patient's psychological or behavioral needs produces successful behavior change. However, health care providers have limited available resources to deliver a patient-centered approach for their psychological or behavioral needs, resulting in a current one-size-fits-all strategy due to the nonfeasible nature of existing surveys. The solution would be to provide health care professionals with a clinically feasible questionnaire that identifies the patient's personal psychological and behavioral factors related to adherence.

OBJECTIVE

We aim to apply the capability, opportunity, and motivation model of behavior change (COM-B) questionnaire to detect a patient's perceived psychological and behavioral barriers to adherence. Additionally, we aim to explore the key psychological and behavioral barriers indicated by the COM-B questionnaire and adherence to treatment in patients with confirmed asthma with heterogeneous severity. Exploratory objectives will include a focus on the associations between the COM-B questionnaire responses and asthma phenotype, including clinical, biological, psychosocial, and behavioral components.

METHODS

In a single visit, participants visiting Portsmouth Hospital's asthma clinic with a diagnosis of asthma will be asked to complete a 20-minute questionnaire on an iPad about their psychological and behavioral barriers following the theoretical domains framework and capability, opportunity, and motivation model. Participants' data are routinely collected, including demographics, asthma characteristics, asthma control, asthma quality of life, and medication regime, which will be recorded on an electronic data capture form.

RESULTS

The study is already underway, and it is anticipated that the results will be available by early 2023.

CONCLUSIONS

The COM-B asthma study will investigate an easily accessible theory-based tool (a questionnaire) for identifying psychological and behavioral barriers in patients with asthma who are not adhering to their treatment. This will provide useful information on the behavioral barriers to asthma adherence and whether or not a questionnaire can be used to identify these needs. The highlighted barriers will improve health care professionals' knowledge of this important subject, and participants will benefit from the study by removing their barriers. Overall, this will enable health care professionals to use effective individualized interventions to support improved medication adherence while also recognizing and meeting the psychological needs of patients with asthma.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05643924; https://clinicaltrials.gov/ct2/show/NCT05643924.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44710.

Uso de glucocorticoides sistémicos para el tratamiento del asma grave: Consenso multidisciplinar español

Background and aim

Since their effectiveness was initially demonstrated, oral corticosteroids (OCS) have been routinely used to treat asthma. We now know that their usage is linked to the development of side effects such osteoporosis and adrenal insufficiency. This is an observational study based on Delphi methodology. The questionnaire was divided into 4 sections: OCS generalities, maintenance treatment, short-term treatment, and adverse events.

Materials and methods

Two rounds of a 68-item questionnaire were completed by a panel of 48 allergists and pneumologists.

Results

Definitions were agreed upon, as was the proper use of OCS in the treatment of severe asthma. The experts agreed that the use of OCS should be minimized as much as possible and that in the event of maintenance treatments, a slow and progressive tapering strategy should be used. They also emphasized the importance of standardizing the technique for measuring the amount of SCG delivered in both cases.

Conclusions

This consensus document attempts to bring together scientifically supported suggestions from specialists in the management of asthma to reduce the use of OCS in Spain.

Evaluation of the Antiasthmatic Activity of Carissa opaca in Animal Models

Carissa opaca Stapf ex Haines (C. opaca) fruit is used traditionally in the treatment of respiratory illnesses including asthma. However, there is no scientific evidence supporting its antiasthmatic activity. The current study was conducted to evaluate its antiasthmatic effects using in vivo and in vitro approaches. The methanolic crude extract of C. opaca fruit (Co.Cr.) was used and in vivo antiasthmatic activity was carried out using ovalbumin- (OVA-) sensitized and OVA-challenged BALB/c mice. In in vitro bronchorelaxant activity of crude extract, aqueous and n-hexane fractions of C. opaca were carried out on isolated rat tracheal strips. Co.Cr. (200 and 400 mg/kg) attenuated ovalbumin-induced changes in lung histochemistry with % decrease in peribronchial inflammation of 14.1 ± 0.21 and 65.8 ± 0.22 and % decrease in total inflammatory cell count of 35.7 ± 2.80 and 53.3 ± 2.30 in bronchoalveolar lavage fluid. Co.Cr., aqueous, and n-hexane fraction of C. opaca attenuated the precontractions induced by high K+ (80 mM) and carbachol (1 μM), respectively. In conclusion, the results showed that C. opaca possesses antiasthmatic activity via relaxant effect on bronchial smooth muscle which is mediated through calcium channel blockade and antimuscarinic activity. This study provides scientific evidence of the traditional use of C. opaca in the management of allergic asthma.

Lung function among residents from the largest coal region in Brazil

Coal mining and burning activities in coal-fired power plants are among the most polluting activities in developing countries. In Brazil, the Candiota coal deposit concentrates 40% of the national mineral coal. Although, previous studies indicate several negative health outcomes to residents of this coal region, there is no information about lung function. Thus, this study aimed to evaluate lung function by spirometry among residents from the largest coal mining region of Brazil and its related factors. It was carried out a cross-sectional study with 300 male adults residing in four cities from this region. Socioeconomic, demographic, life style, and health conditions were collected through a structured questionnaire, and lung function was assessed by spirometry. Almost 18% of the residents have disorders in pulmonary function. There was significant statistical difference in the spirometry main parameters between the cities. Candiota city (host city of coal exploration activities) have the highest prevalence of obstructive ventilatory disorder. Curiously, upper economic class had significant higher risk of altered lung function (P<0.001), as well as inappropriate sewage destination (P<0.001). Residents of Candiota city had 20% higher risk of altered lung function. Regarding air quality, the PM₁₀, SO₂, and NO₂ of the region were 20.6± 3.9, 7.0± 2.2, and 6.0± 1.6, respectively. Two air quality stations exceed the limit of 20 μg/m³ to PM₁₀ proposed by Brazilian legislation and WHO, and three stations had PM₁₀ quite close to the limit. This study points out the need for urgent action to protect residents from this coal mining region.

Prevalence of asthma among children in India: A systematic review and meta-analysis

There is a lack of national-level estimates on the magnitude of asthma among children in India. Hence, we undertook a systematic review and meta-analysis to estimate the prevalence of asthma among children in India. We searched PubMed, Embase, Cochrane Library, and Google Scholar, and included cross-sectional studies reporting data on the prevalence of asthma among children in India. A random-effects model was used to estimate the pooled prevalence of asthma. In the 33 selected studies (pooled sample of 167,626 children), the estimated prevalence of asthma was 7.9% (95% confidence interval: 6.3-9.6%), I2 = 99.1% (P < 0.001). The prevalence was higher among boys and in urban areas. Appropriate training and resources should be made available at the primary healthcare level for early detection and management of asthma in children. A nationwide population-based survey is indicated to provide reliable estimates of the burden of asthma.

Dioscin exhibits protective effects on in vivo and in vitro asthma models via suppressing TGF-β1/Smad2/3 and AKT pathways

Dioscin is a natural product that possesses protective effects on multiple chronic injuries, but its effects on asthma are not fully understood. Herein, we evaluated its effects on asthmatic mice established by ovalbumin (OVA) sensitization and challenges and further explored the mechanism. Inflammatory cells in bronchoalveolar lavage fluids (BALFs) were analyzed using Diff-Quik staining. OVA-specific immunoglobulin E (IgE)/IgG1 in serum and inflammatory cytokines (interleukin 4[IL-4], IL-5, IL-13, and tumor necrosis factor-α) in BALFs and lung tissues were measured using Enzyme-Linked Immunosorbent Assay Kits. Hematoxylin and eosin, periodic acid-Schiff, and immunohistochemistry staining showed histopathological changes in lung tissues. Epithelial-mesenchymal transition (EMT) in human bronchial epithelial (16HBE) cells was assessed by immunofluorescence staining. Hydroxyproline content was used to evaluate collagen deposition. Polymerase chain reaction and Western blot were performed to measure messenger RNA and protein expression. We found that dioscin treatment (particularly at the dose of 80 mg/kg) significantly inhibited pulmonary inflammation in asthmatic mice, as evidenced by the decreased serum OVA-specific IgE/IgG1 and the reduced inflammatory cells and cytokines in BALFs and lung tissues. Moreover, dioscin effectively ameliorated the goblet cell hyperplasia, mucus hypersecretion, collagen deposition, and smooth muscle hyperplasia in the airways of asthmatic mice. Mechanistically, dioscin restrained the activated TGF-β1/Smad2/3 and protein kinase B (AKT) signal pathways in lung tissues and potently reversed the TGF-β1-induced EMT and phosphorylation of Smad2/3 and AKT in 16HBE cells. Collectively, dioscin displayed protective effects on OVA-induced asthmatic mice via adjusting TGF-β1/Smad2/3 and AKT signal pathways, supporting the fact that dioscin could be a candidate for chronic asthma prevention in the future.

Metabolomic profiling reveals extensive adrenal suppression due to inhaled corticosteroid therapy in asthma

The application of large-scale metabolomic profiling provides new opportunities for realizing the potential of omics-based precision medicine for asthma. By leveraging data from over 14,000 individuals in four distinct cohorts, this study identifies and independently replicates 17 steroid metabolites whose levels were significantly reduced in individuals with prevalent asthma. Although steroid levels were reduced among all asthma cases regardless of medication use, the largest reductions were associated with inhaled corticosteroid (ICS) treatment, as confirmed in a 4-year low-dose ICS clinical trial. Effects of ICS treatment on steroid levels were dose dependent; however, significant reductions also occurred with low-dose ICS treatment. Using information from electronic medical records, we found that cortisol levels were substantially reduced throughout the entire 24-hour daily period in patients with asthma who were treated with ICS compared to those who were untreated and to patients without asthma. Moreover, patients with asthma who were treated with ICS showed significant increases in fatigue and anemia as compared to those without ICS treatment. Adrenal suppression in patients with asthma treated with ICS might, therefore, represent a larger public health problem than previously recognized. Regular cortisol monitoring of patients with asthma treated with ICS is needed to provide the optimal balance between minimizing adverse effects of adrenal suppression while capitalizing on the established benefits of ICS treatment.

Validity of a portable spirometer in the communities of China

Background

The lack of simple and affordable spirometry has led to the missed and delayed diagnoses of chronic respiratory diseases in communities. The PUS201P is a portable spirometry developed to solve this problem.

Objective

We aimed to verify the consistency of the PUS201P spirometer with conventional Jaeger spirometer.

Methods

In this cross-sectional study, we randomly recruited 202 subjects aged > 40 years. Testing with the portable spirometry and conventional spirometry were performed on all participants. We compared forced expiratory volume in one second (FEV₁), forced vital capacity (FVC), FEV₁/FVC measured by the PUS201P device with the conventional spirometer. Pearson correlation coefficient and Interclass Correlation Coefficient (ICC) were assessed to confirm the consistency of the measures from two instruments. Bland–Altman graph was created to assess the agreement of the measures from two devices.

Results

202 participants were included in this study. The ICC on FEV₁, FVC, FEV₁/FVC measured by the portable spirometer and the conventional spirometer were 0.95 (95% confidence interval [CI]: 0.94–0.96), 0.92 (95% CI: 0.90–0.94], 0.93 (95% CI: 0.91–0.95), respectively. The Bland–Altman plots showed that the mean difference between the measures from two spirometers are always located in the 95% limits of agreement.

Conclusions

Our results support that the measures from the portable spirometer and the conventional spirometer have a good agreement and reproducibility. And the portable spirometer is a reliable tool to screen and diagnose chronic airway diseases in the primary care settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01872-9.

Clinical and Lung Function Outcomes After Anti-IgE or Anti-IL5 Therapy in Severe Asthma

Background

Although there have been indirect comparisons of the relative efficacy of mepolizumab (anti-IL-5) and benralizumab (anti-IL-5Rα) in severe asthma patients, long-term direct head-to-head comparisons are lacking. Here, we (i) examined the effect of mepolizumab, benralizumab, and omalizumab on symptom control and lung function parameters over time; and (ii) compared the efficacy of mepolizumab and benralizumab on symptom control and lung function outcomes.

Methods

This was a retrospective study of patients with severe asthma taking anti-IgE (omalizumab; n = 24), anti-IL5 (mepolizumab, n = 23), or anti-IL-Rα (benralizumab; n = 12) therapy. Data were extracted on (i) Asthma Control Questionnaire (ACQ-5) scores; (ii) forced expiratory volume over 1 second (FEV₁); and (iii) peak expiratory flow rate (PEFR) at 4–6 months and 1 year and documented reductions in exacerbations. Clinical and lung function outcomes were compared between patients taking mepolizumab and benralizumab and over time.

Results

There were significant decreases in ACQ-5 scores (3.3 ± 0.93 to 1.7 ± 0.98 for mepolizumab, 3.5 ± 0.72 to 1.6 ±0.89 for benralizumab, and 3.5 ± 0.95 to 1.7 ± 1.1 for omalizumab; t-test, all p < 0.0001) but not increases in FEV₁ and PEFR for all three agents after 4–6 months of therapy, which persisted but did not decrease further at one year. There were trends toward a greater percentage increase in FEV₁ and PEFR from baseline and a decrease in the number of exacerbations in patients taking benralizumab than those taking mepolizumab.

Conclusion

Although limited by a small sample size, this real-world, head-to-head comparison of mepolizumab and benralizumab is consistent with comparative data on asthma biologicals and indirect comparisons showing no major difference in efficacy. The study also generates new testable hypotheses about the efficacy of asthma biologicals in different patient populations.

Level of Knowledge About COPD Among Patients and Caregivers

Chronic obstructive pulmonary disease (COPD) represents a major health burden worldwide. COPD-specific education may positively affect the emotional distress associated with the disease and may contribute to the patients' poor health-related quality of life. Studies have shown that education regarding COPD is lacking among disease sufferers. The aim of our study was to evaluate the knowledge of COPD among patients and caregivers. We used the Bristol COPD Knowledge Questionnaire in hospitalized and nonhospitalized patients with COPD and other pulmonary diseases, their caregivers, and healthy volunteers. Mean total knowledge score of patients with COPD was 24.27 ± 8.44, of patients with other respiratory diseases 25.53 ± 7.93, of caregivers of patients with COPD 21.80 ± 5.32, of caregivers of patients with other pulmonary diseases 23.50 ± 8.79, and of healthy subjects 25.85 ± 9.27 (p = 0.071). Our data further indicate the lack of knowledge of COPD among patients and their carers and emphasize the need of education programs.

Epigenetic regulation is involved in traffic-related PM2.5 aggravating allergic airway inflammation in rats

Increasing fine particulate matter (PM_2.5) and epigenetic modifications are closely associated with the pathogenesis of asthma, but the definite mechanism remains unclear. The traffic-related PM_2.5 exposure aggravated pulmonary inflammation and changed the methylation level of interferon gamma (Ifng) and interleukin (Il)4 genes, and then altered levels of affiliated cytokines of IFN-γ and IL-4 in rats with allergic airway inflammation. It also increased the level of miR146a and decreased the level of miR31. In addition, transcription factors of nuclear factor kappa B (NF-κB) and signal transducer and activator of transcription 6 (Stat6) rose; forkhead box P3 (Foxp3) and signal transducer and activator of transcription 4 (Stat4) lowered. The traffic-related PM_2.5 altered epigenetic modifications in allergic airway inflammation of rats leading to inflammation exacerbation through impaired regulatory T (Treg) cells function and T-helper type 1 (Th1)/Th2 cells imbalance, which provided a new target for the treatment and control of asthma.

Pharmaco-Metabolomics of Inhaled Corticosteroid Response in Individuals with Asthma

Metabolomic indicators of asthma treatment responses have yet to be identified. In this study, we aimed to uncover plasma metabolomic profiles associated with asthma exacerbations while on inhaled corticosteroid (ICS) treatment. We determined whether these profiles change with age from adolescence to adulthood. We utilized data from 170 individuals with asthma on ICS from the Mass General Brigham Biobank to identify plasma metabolites associated with asthma exacerbations while on ICS and examined potential effect modification of metabolite-exacerbation associations by age. We used liquid chromatography-high-resolution mass spectrometry-based metabolomic profiling. Sex-stratified analyses were also performed for the significant associations. The age range of the participating individuals was 13-43 years with a mean age of 33.5 years. Of the 783 endogenous metabolites tested, eight demonstrated significant associations with exacerbation after correction for multiple comparisons and adjusting for potential confounders (Bonferroni p value < 6.2 × 10^-4). Potential effect modification by sex was detected for fatty acid metabolites, with males showing a greater reduction in their metabolite levels with ICS exacerbation. Thirty-eight metabolites showed suggestive interactions with age on exacerbation (nominal p-value < 0.05). Our findings demonstrate that plasma metabolomic profiles differ for individuals who experience asthma exacerbations while on ICS. The differentiating metabolites may serve as biomarkers of ICS response and may highlight metabolic pathways underlying ICS response variability.

Evaluation of choroidal thickness in children with acute asthma attack by optical coherence tomography

OBJECTIVE

To evaluate the change in central choroidal thickness in children with asthma attack before and after treatment with β₂ agonists.

MATERIALS AND METHODS

About 100 eyes of 50 patients (5-17 years old) with visual acuity of 20/20 who had no retinal, choroidal, and systemic comorbidity were examined by enhanced depth optical coherence tomography (EDI-OCT) before and after asthma attack treatment. Sixty eyes of 30 healthy children of similar age and gender were evaluated as the control group. The central choroidal thickness, peak expiratory flow (PEF), forced expiratory volume 1(FEV₁), oxygen saturation, and heart rate were evaluated.

RESULTS

The mean age of the patients was 9.2 ± 3.1 years, and the mean saturation values of patients was 97.2 ± 1.3 before treatment, and it increased to 98.3 ± 0.9 after treatment with a statistically significant difference. The mean FEV₁ values were 80.8 ± 15.2 before, and 92.7 ± 12.9 after the treatment and PEF values were 75.9 ± 18.6 before and 89.3 ± 18.9 after treatment. This differences were statistically significant (p < 0.001). The average choroidal thickness before the treatment were 310.4 ± 34.2 μm and decreased to 302.7 ± 34.4 μm after the treatment, this decrease was statistically significant (p < 0.001). The mean choroidal thickness of the control group was 303.0 ± 7.3 μm and compared to the pre-treatment and post-treatment values, it was more similar to the post-treatment values, although there was no statistically difference.

CONCLUSION

In our study, it was shown that choroidal thickness was significantly reduced in children with asthma who received attack treatment with β₂ agonists, and it was similar to the control group after the treatment.

Protocol for a scoping review to evaluate the extent of utilisation of healthcare services by asthma patients in sub-Saharan African countries

INTRODUCTION

Health systems in sub-Saharan African (SSA) countries are fragile and centralised. Consequently, majority of people have restricted access to healthcare services. Given the rise in the prevalence and burden of asthma in SSA, it is imperative to scrutinise the utilisation of healthcare services by people with asthma. We aim to understand, through this review, the extent of utilisation of healthcare services by asthma patients in SSA countries.

METHODS AND ANALYSIS

Arksey and O'Malley's scoping review methodology framework will be used to guide the conduct of this scoping review. We will conduct a search of the literature on the electronic databases: Medline, (using PubMed interface), EMBASE, EBSCOHOST, Web of Science and Google Scholar, grey literature sources and the reference lists of key studies to identify studies appropriate for inclusion. Two reviewers will independently screen all abstracts and full-text studies for inclusion. Registration of the proposed scoping review on the PROSPERO has indicated that no similar work has been or is being done elsewhere. We will review studies published on the subject from January 2009 to May 2020 in SSA.

ETHICS AND DISSEMINATION

The proposed scoping review will contribute towards the knowledge base on utilisation of healthcare services particularly for people with asthma. This will provide a better understanding of the extent of utilisation of healthcare services by asthma patients and ultimately contribute to improvement of quality of care for people suffering from asthma. The results from the review will enlighten and guide healthcare practitioners and researchers on developing appropriate and feasible interventions to increase the utilisation of healthcare services by asthma patients in resource-constrained settings in SSA countries. Results of this scoping review will be disseminated through a peer-reviewed publication, conference presentations and a 1-day stakeholder meeting.

PROSPERO REGISTRATION NUMBER

CRD42020154127.

Spatial Modeling of Asthma-Prone Areas Using Remote Sensing and Ensemble Machine Learning Algorithms

In this study, asthma-prone area modeling of Tehran, Iran was provided by employing three ensemble machine learning algorithms (Bootstrap aggregating (Bagging), Adaptive Boosting (AdaBoost), and Stacking). First, a spatial database was created with 872 locations of asthma patients and affecting factors (particulate matter (PM10 and PM2.5), ozone (O3), sulfur dioxide (SO2), carbon monoxide (CO), nitrogen dioxide (NO2), rainfall, wind speed, humidity, temperature, distance to street, traffic volume, and a normalized difference vegetation index (NDVI)). We created four factors using remote sensing (RS) imagery, including air pollution (O3, SO2, CO, and NO2), altitude, and NDVI. All criteria were prepared using a geographic information system (GIS). For modeling and validation, 70% and 30% of the data were used, respectively. The weight of evidence (WOE) model was used to assess the spatial relationship between the dependent and independent data. Finally, three ensemble algorithms were used to perform asthma-prone areas mapping. According to the Gini index, the most influential factors on asthma occurrence were distance to the street, NDVI, and traffic volume. The area under the curve (AUC) of receiver operating characteristic (ROC) values for the AdaBoost, Bagging, and Stacking algorithms was 0.849, 0.82, and 0.785, respectively. According to the findings, the AdaBoost algorithm outperforms the Bagging and Stacking algorithms in spatial modeling of asthma-prone areas.

Innate Lymphoid Cells in Airway Inflammation

Airways are constantly exposed to antigens and various pathogens. Immune cells in the airways act as first line defense system against these pathogens, involving both innate and acquired immunity. There is accumulating evidence that innate lymphoid cells, newly identified lymphoid lineage cells, play a critical role in regulating tissue homeostasis and in the pathogenesis of inflammation. Cytokines produced by other cells activate innate lymphoid cells, which in turn produce large amount of cytokines that result in inflammation. Type 2 innate lymphoid cells (ILC2s) are recognized as key component of T helper type 2 (Th2) inflammation, and are known to be elevated in type 2 (T2) human airway diseases (asthma). Th2 cytokines produced by ILC2s amplify inflammation via activation of eosinophils, B cells, mast cell, and macrophages. "T2 high asthma" has an increased Th2 response triggered by elevation of IL-4, IL-5 and IL-13 and other inflammatory mediators, leading to increased eosinophilic inflammation. The growing evidence of ILC2 contribution in the induction and maintenance of allergic inflammation suggests that targeting upstream mediators may affect both the innate and adaptive immune responses and all disease phenotypes. Blocking ILC2 activators, activation of inhibitory pathways of ILC2, or suppression of ILC2-mediated pathways may be therapeutic strategies for the type 2 airway diseases.

Beneficial Immunomodulatory Effects of Fluticasone Propionate in Chlamydia pneumoniae-Infected Mice

The associations between inhaled corticosteroid (ICS) use and pulmonary infections remains controversial. Chlamydia pneumoniae (C. pneumoniae) accounts for asthma exacerbations; however, there are no data regarding ICS effects on C. pneumoniae infections. Thus, we investigated whether fluticasone propionate (FP) or budesonide (BUD) could affect C. pneumoniae infection in vitro and in vivo, focusing on the possible mechanisms that lead to potential anti-chlamydial outcomes. We performed direct qPCR to detect C. pneumoniae growth in infected, FP-treated, and BUD-treated A549 cells. Furthermore, FP or BUD was administered by inhalation to C. pneumoniae-infected mice. The recoverable C. pneumoniae was determined by indirect immunofluorescence. Expression levels of interferon (IFN)-γ and IFN-γ inducible chemokines were assessed by qPCR. We measured the protein concentrations of IFN-γ and of other cytokines that potentially participate in the anti-chlamydial response by ELISA. We found that FP treatment suppressed Chlamydia growth in A549 cells and in mice. Higher levels of IFN-γ gene expression were observed in FP-treated mice compared to the untreated and BUD-treated mice (p < 0.0001). IFN-γ and anti-chlamydial protein MIG/CXCL9 values were significantly higher after FP inhalation. Collectively, FP, but not BUD, suppressed C. pneumoniae growth in vitro and in vivo, which was likely due to the enhanced IFN-γ related responses.

Comparison of fractional exhaled nitric oxide in asthmatics with and without allergic rhinitis

PURPOSE OF THE STUDY

The aim of this study was to measure the concentration of FeNO in asthmatics with and without allergic rhinitis (AR) and to determine usefulness of the test in the assessment of asthma control in the Polish population. The next objective of this study was to estimate the cut-off point of FeNO which might be a good indicator of uncontrolled asthma.

MATERIALS AND METHODS

The measurements were taken using the Hyp'Air FeNO in 303 adult patients with asthma, AR, comorbid AR and asthma, and non-diseased volunteers.

RESULTS

FeNO level in healthy adults was similar to the FeNO concentration in AR as well as controlled asthmatic patients without and with AR. Patients with partly controlled and uncontrolled asthma with and without AR had higher FeNO (>60 ppb) levels when compared to adults with controlled disease. The optimal cut-off point of FeNO > 46 ppb and FeNO > 33 ppb was estimated for identification of uncontrolled asthmatics without and with AR, respectively.

CONCLUSION

In conclusion, we found a significant correlation between the FeNO concentration and the level of asthma symptom control in asthmatic patients with and without AR.

Association of serum chemokine ligand 21 levels with asthma control in adults

OBJECTIVES

The chemokine ligand (CCL) 21 regulates the maturation, migration, and function of dendritic cells, and has been implicated in the pathogenesis of asthma. This study aimed to investigate the association between serum CCL21 levels and asthma control.

METHODS

The serum levels of CCL21 and other inflammatory cytokines were analyzed in patients with asthma (n=44) and healthy controls (n=35) by enzyme-linked immunosorbent assay. IgE levels and eosinophil counts were determined by turbidimetric inhibition immunoassay and fully automatic blood analysis, respectively. The Asthma Control Test (ACT) questionnaire was used, and spirometry and fractional exhaled nitric oxide (FENO) measurements were performed. A multiple unpaired Student's t-test was performed to analyze the differences in CCL21 and interleukin levels between patients with asthma and healthy controls. The correlation of CCL21 levels with disease severity was evaluated using the Pearson's rank correlation test.

RESULTS

Serum CCL21 levels were lower in patients with asthma (254.78±95.66 pg/mL) than in healthy controls (382.95±87.77 pg/mL) (p<0.001). Patients with asthma had significantly higher levels of IL-1β (19.74±16.77 vs. 2.63±5.22 pg/mL), IL-6 (7.55±8.65 vs. 2.37±2.47 pg/mL), and tumor necrosis factor-α (12.70±12.03 vs. 4.82±3.97 pg/mL) compared with the controls. CCL21 levels were positively correlated with the ACT score (rs=0.1653, p=0.0062), forced expiratory volume in 1s (FEV1)/forced vital capacity (rs=0.3607, p<0.0001), and FEV1 (rs=0.2753, p=0.0003), and negatively correlated with FENO (rs=0.1060, p=0.0310). CCL21 levels were negatively correlated with serum IgE levels (rs=0.1114, p=0.0268) and eosinophil counts (rs=0.3476, p<0.0001).

CONCLUSIONS

Serum CCL21 levels may be a new biomarker for assessing asthma control.

Therapeutic Inertia in Prescribing Biologics for Patients with Moderate-to-Severe Asthma: Workshop Summary

Moderate-to-severe asthma represents about a quarter of the nearly 10% of Americans diagnosed with asthma. Many patients with moderate-to-severe asthma have uncontrolled symptoms that lead to exacerbations requiring oral corticosteroids. There are many factors contributing to poor asthma control, including poor adherence to prescribed therapies, the under-prescribing of biologics and therapeutic inertia. We convened an eight-member panel from fields of primary care, pulmonology, immunology, health services and clinical research, behavioral science and pharmaceutical medical affairs, with the goal of identifying contributing factors and solutions to therapeutic inertia with asthma biologics. We used the Capability, Opportunity, and Motivation (COM-B) model to classify patient and provider behavior towards therapeutic inertia. The model incorporates existing behavior theories and is driven by the interaction of capability, opportunity, and motivation. We used a Delphi method to identify and develop six primary solutions: 1) integration of patient-centered outcomes into asthma management practice; 2) provider education about asthma treatment; 3) moderate-to-severe asthma care delivery redesign; 4) harmonized, evidence-based protocol for the management of moderate-to-severe asthma; 5) designated coordinator approach for optimal asthma management; and 6) a case coordination digital support tool. Integration of patient-centered outcomes into asthma management practice and provider education were identified as having the highest potential to impact therapeutic and clinical inertia. The COM-B model is effective in identifying improvement within therapeutic inertia targeting the capabilities, opportunities, and motivations of patients, providers, and payer systems.

Borneol inhibits CD4 + T cells proliferation by down-regulating miR-26a and miR-142-3p to attenuate asthma

BACKGROUND

Asthma is a chronic airway inflammatory disease caused by a variety of cytokines and signaling pathways closely related to immunoregulation. Corticosteroids are the most widely used drug in the asthma treatment. However, the use of corticosteroids could cause topical side effects. So, it's important to find new drugs for asthma treatment. Our study aims to explore the pharmacological effect of borneol on asthma and its underlying mechanism.

METHODS

We constructed the OVA-induced asthma model to investigate the effect of borneol on asthma in mice. HE and PAS staining was used to detect the effect of borneol on pathological change of mice with asthma. Inflammatory cytokines were measured by ELISA. qRT-PCR was used to explore the effect of borneol on microRNAs expression. Cell proliferation of CD4 + T cells was detected by CCK-8 assay and flow cytometry. Western blot was used to detect pten expression and Akt activation.

RESULTS

We found that borneol significantly alleviated asthma progression in mice. Borneol inhibited CD4 + T cells infiltration in vivo and proliferation in vitro by downregulating miR-26a and miR-142-3p. miR-26a and miR-142-3p promoted CD4 + T cells proliferation in vitro through targeting Pten. Overexpression of miR-26a and miR-142-3p abolished the effect of borneol in vivo.

CONCLUSION

In a word, these findings suggested that borneol attenuated asthma in mice by decreasing the CD4 + T cells infiltration. The molecular mechanism of borneol was dependent on the downregulation of miR-26a and miR-142-3p to upregulate the Pten expression.

Treatment with the anti-IgE monoclonal antibody omalizumab in women with asthma undergoing fertility treatment: a proof-of-concept study-The PRO-ART study protocol

INTRODUCTION

Asthma is associated with prolonged time to pregnancy and a higher need for fertility treatment. However, the mechanism underlying this association remains incompletely understood. Previous research points to asthma-driven systemic inflammation also affecting the reproductive organs and thereby fertility. The aim of this study was to determine if treatment with omalizumab prior to fertility treatment will increase pregnancy rate among women with asthma by decreasing the systemic asthma-related inflammation and, by that, to provide insight into the underlying mechanisms.

METHODS AND ANALYSIS

This is an ongoing prospective multicentre randomised controlled trial planned to enrol 180 women with asthma recruited from fertility clinics in Denmark. The patients are randomised 1:1 to either omalizumab or placebo. The primary endpoint is the difference in pregnancy rate confirmed with ultrasound at gestational week 7 of pregnancy. The secondary endpoints are change in sputum and blood eosinophil cell count, change in biomarkers, change in microbiota, together with rate of pregnancy loss, frequency of malformations, pre-eclampsia, preterm birth, birth weight, small for gestational age and perinatal death between groups.

ETHICS AND DISSEMINATION

The methods used in this study are of low risk, but if successful, our findings will have a large impact on a large group of patients as infertility and asthma are the most common chronic diseases among the young population. The study has been approved by the Ethics Committee-Danish national research ethics committee (H-18016605) and the Danish Medicines Agency (EudraCT no: 2018-001137-41) and the Danish Data Protection Agency (journal number: VD-2018486 and I-Suite number 6745). The test results will be published regardless of whether they are positive, negative or inconclusive. Publication in international peer-reviewed scientific journals is planned.

TRIAL REGISTRATION NUMBER

NCT03727971.

Reducing oral corticosteroids in severe asthma (ROSA Project): a nationwide Portuguese consensus

INTRODUCTION AND OBJECTIVES

We aimed to build a national consensus to optimize the use of oral corticosteroids (OCS) in severe asthma in Portugal.

MATERIAL AND METHODS

A modified 3-round Delphi including 65 statements (topics on chronic systemic corticotherapy, therapeutic schemes, asthma safety and monitoring) was performed via online platform (October-November 2019). A five-point Likert-type scale was used (1-'strongly disagree'; 5-'strongly agree'). Consensus threshold was established as a percentage of agreement among participants ≥90% in the 1st round and ≥85% in the 2nd and 3rd rounds. The level of consensus achieved by the panel was discussed with the participants (face-to-face meeting).

RESULTS

Forty-eight expert physicians in severe asthma (specialists in allergology and pulmonology) participated in the study. Almost half of the statements (28/65; 43.1%) obtained positive consensus by the end of round one. By the end of the exercise, 12 (18.5%) statements did not achieve consensus. Overall, 87% of physicians agree that further actions for OCS cumulative risk assessment in acute asthma exacerbations are needed. The vast majority (91.7%) demonstrated a favorable perception for using biological agents whenever patients are eligible. Most participants (95.8%) are more willing to accept some degree of lung function deterioration compared to other outcomes (worsening of symptoms, quality of life) when reducing OCS dose. Monitoring patients' comorbidities was rated as imperative by all experts.

CONCLUSIONS

These results can guide an update on asthma management in Portugal and should be supplemented by studies on therapy access, patients' adherence, and costs.

A narrative review of research advances in mesenchymal stem cell therapy for asthma

Asthma is a chronic inflammatory disease of the airways that involves multiple cells, including inflammatory cells, structural cells, and cellular components. Glucocorticoids and beta-receptor agonists are still the first choices for asthma treatment. However, the asthma symptoms may still be poorly controlled in some patients after an optimal treatment. Mesenchymal stem cells (MSCs) are characterized by the potential for multi-directional differentiation and can exert immunomodulatory and anti-inflammatory effects. Its role in treating asthma has increasingly been recognized in recent years. In this review article, we sought to summarize the recent advances in the therapeutic effects of MSCs on several types of asthma and explain the relevant mechanisms. Articles on asthma treatment with MSCs as of January 2020 were searched in PubMed, Google Scholar, and Web of Science databases. It was found that MSCs have therapeutic effects on allergic asthma, non-allergic asthma and occupational asthma; gene-modified or pretreated MSCs improves the therapeutic effects of MSCs in asthma; MSC-derived conditioned medium or extracellular vesicles possess the considerable curative effect as MSC on asthma; and MSCs exert their therapeutic effects on asthma by restoring Th1/Th2 balance, reversing Th17/Tregs imbalance, inhibiting DC maturation, and promoting the switch of M1 to M2 and repairing epithelial injury. Thus, MSCs may be a promising treatment for asthma.

The Effect of Asthma Severity on Perinatal Outcomes: A Tertiary Hospital Experience

OBJECTIVE

To evaluate the effect of asthma severity and disease exacerbation on pregnancy outcomes.

MATERIALS AND METHODS

Pregnancies were classified into 3 groups as mild (n=195), moderate (n=63), and severe (n=26) according to preconceptional asthma severity. Demographic features, clinical characteristics, and perinatal outcomes were compared between the groups. Delivery characteristics and pregnancy outcomes were also compared between the pregnancies with or without asthma exacerbation (43 and 241 pregnancies, respectively).

RESULTS

Worsening of symptoms during pregnancy was higher in moderate and severe asthma groups (p<0.001). Rates of spontaneous abortion, fetal structural anomaly, preterm delivery, preeclampsia, fetal growth restriction (FGR), oligohydramnios, gestational diabetes, and intrauterine fetal demise were higher in moderate and severe asthma groups (p-values were < 0.001, 0.01, 0.008, 0.02, 0.01, < 0.001, < 0.001, and 0.007, respectively). Admissions to neonatal intensive care units and neonatal complication rates were higher among moderate and severe asthma groups (p=0.035 and < 0.001). Spontaneous abortion, preterm delivery, preeclampsia, FGR, oligohydramnios, and neonatal complication rates were higher (p<0.001) in the group with exacerbated symptoms.

CONCLUSION

Moderate to severe asthma before pregnancy and the exacerbation of asthma symptoms during pregnancy may lead to increased rates of perinatal complications.

Assessing the nature of asthma in African epidemiological studies: a scoping review protocol

BACKGROUND

Asthma is one of the most common chronic respiratory conditions in the world and is increasing in prevalence, particularly in Africa and other low-income countries. The disproportionately high numbers of premature deaths and severe or uncontrolled cases in many African countries are indicative of their inability to cope with a costly disease like asthma. Progress has, however, been made in understanding the complex and heterogeneous nature of the disease. The objective of this study will be to summarise the epidemiological literature on the nature of asthma in African countries.

METHODS

We registered a study protocol for a scoping review. The review was designed following the Arksey and O'Malley framework. We will search PubMed/MEDLINE, African Journals Online (AJOL) and relevant grey literature (e.g. Google Scholar, EBSCOhost) from January 1990 onwards. Only primary epidemiological studies of asthma (e.g. frequency, disease mechanisms, associated risk factors and comorbidities) written in English and conducted in Africa will be included. Two reviewers will independently screen all citations, full-text articles and abstract data. Potential conflicts will be resolved through discussion. Findings will be reported using narrative synthesis and tabulation of the summaries.

DISCUSSION

This scoping review will capture the state of the current epidemiological literature on asthma in African countries. Results will be published in a peer-reviewed journal. We anticipate this review will identify gaps and make recommendations for future areas of study.

SCOPING REVIEW REGISTRATION

Open Science Framework http://osf.io/n2p87/.

Treadmill exercise ameliorates memory deficits and hippocampal inflammation in ovalbumin-sensitized juvenile rats

The behavioral changes, including spatial learning and memory impairment as well as depressive- and anxiety-like behaviors in an animal model of asthma were demonstrated previously. On the other hand, there is increasing evidence that the anti-inflammatory actions of exercise are related to their neuroprotective properties against different insults in the brain. This study was aimed to explore the effects of moderate treadmill exercise on cognitive deficits and possible anti-inflammatory mechanisms in ovalbumin (OVA)-sensitized rats. The exercise groups were trained to run on the treadmill 30 min/day with an intensity of 12 m/min, 5 days/week for 4 weeks. Animals in the OVA groups were sensitized by two intraperitoneal (i.p.) injections of OVA (10 μg/injection) and challenged with OVA by inhalation during the treadmill running exercise period. Passive avoidance (PA) memory, levels of interleukin (IL)-10 and tumor necrosis factor (TNF)-α in the hippocampus, total and differential white blood cell (WBC) count in the blood as well as pathological changes of the lung were then evaluated. OVA-sensitization was resulted in cognitive deficits in the PA task, along with increased total and differential WBC in blood and TNF-α in the hippocampus. However, exercise ameliorated these changes and increased the IL-10 level in the hippocampus, suggesting that moderate treadmill exercise can improve memory impairment in OVA-sensitized rats due to its anti-inflammatory properties.

Perspectives of general practitioners about a collaborative asthma care model in primary care

INTRODUCTION

Asthma affects 2.7 million people in Australia and is predominantly managed by general practitioners (GPs) within primary care. Despite national focus on this condition, asthma control in the population is suboptimal, with many preventable hospitalizations. In the light of robust evidence supporting the role of pharmacists in the management of chronic diseases including asthma, the Australian Medical Association (AMA) proposed a General Practice Pharmacist (GPP) model in 2015. In this proposal, a non-dispensing pharmacist, co-located within the primary care setting and collaborating with GPs and allied health professionals, can make a positive impact on patients' health and minimize costs due to medication misadventure. The aim of this study was to obtain the views of GPs regarding the GPP model for better management of asthma in a qualitative study.

METHODS

Semi-structured interviews were conducted with 23 GPs, audio-recorded, transcribed verbatim, and later analyzed for emergent themes. The GPs support the idea of a GPP as time and task pressures restrict them in adhering to asthma management guidelines.

RESULTS

Support from another health professional in such a pressured environment can positively impact patient's health. Funding, clear role delineation within general practice, training of pharmacists working as GPPs, and effective communication systems were described as the potential catalysts for the success of the model.

CONCLUSION

Sustainable funding and the willingness of practice owners/managers were described as the barriers. The GPs agreed that pharmacists can make a positive difference in patient's asthma management once the barriers were effectively addressed.

Anti-Contractile and Anti-Inflammatory Effects of Diacerein on Isolated Mouse Airways Smooth Muscle and Mouse Asthma Model

Characterized by abnormal smooth muscle contractility and airway inflammation, asthma is one of the most common airway diseases worldwide. Diacerein is a well-known anti-inflammatory drug, widely used in osteoarthritis. In current study, the innovative usage of diacerein in anti-contractile and anti-inflammatory treatment of asthma was studied. In vitro experiments including tension measurement and patch-clamp technique and in vivo experiments including establishment of mice model and measurement of respiratory resistance were applied to explore the role of diacerein in asthma. It turned out that agonist-precontracted mouse airway smooth muscle could be relaxed by diacerein via intracellular and extracellular calcium mobilization which was mediated by switched voltage-dependent L-type Ca²⁺ channels, non-selective cation channels, large-conductance Ca²⁺-activated K⁺ channel, and Na⁺/Ca²⁺ exchangers. Furthermore, diacerein could relieve bronchospasm and control airway inflammation in asthmatic mice via reduction of several inflammatory factors. Our studies elucidated the potential therapeutic property of diacerein in asthma treatment and the possible underlying mechanism. It also confirmed that new uses for already-approved drugs could be an important form of innovation.

Mesenchymal Stem Cells in Asthma

Asthma is one of the worldwide respiratory health problem that affect children and adult. Current treatment strategies such as conventional and allergen immunotherapy still fall behind. Mesenchymal stem cells (MSCs) have wide regenerative capacity and immunoregulatory activity with their wide range of secretions and contact dependent manner. In this review, we focus on the current treatment strategies for asthma and MSCs as a new therapeutic tool.

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

Background

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

Method

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

Results

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

Conclusion

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

The use of short-acting beta-2 adrenergic receptor agonists for asthma increased among Finnish and Swedish children from 2006 to 2017

AIM

Paediatric asthma hospitalisation has decreased in Finland, but has remained stable in Sweden. The reasons for these intercountry differences are unclear. The aim of this study was to explore the trend of dispensed asthma medication, including inhaled corticosteroids (ICS), among paediatric populations in the two countries.

METHODS

We explored trends in dispensed asthma medication among paediatric populations aged 0-19 in Finland and Sweden from 2006 to 2017. The Finnish Statistics on Reimbursements for Prescription Medicines and The Swedish Prescribed Drug Register provided data on all dispensed asthma prescriptions.

RESULTS

During the study period, the prevalence of dispensed ICS in paediatric populations was fairly stable in Finland and Sweden. Among children aged 0-4, ICS were 1.5 times more commonly dispensed in Sweden than in Finland. The prevalence of children dispensed short-acting beta-2 adrenergic receptor agonists (SABA) increased in both countries, but rose more in Finland (51%) than in Sweden (27%).

CONCLUSION

Inhaled corticosteroids were more commonly dispensed for children aged 0-4 in Sweden than in Finland during the study period. This study showed an increasing prevalence of children dispensed SABA in Finland and Sweden, particularly in Finland. Differences and trends in asthma medication may effect asthma hospitalisation and asthma deaths.