Time Trend Analysis of the Prevalence and Incidence of Diagnosed Asthma and Traditional Chinese Medicine Use among Adults in Taiwan from 2000 to 2011: A Population-Based Study

Association of blood lipid profiles and asthma: A bidirectional two-sample Mendelian randomization study

BACKGROUND

Observational studies and meta-analyses have indicated associations between blood lipid profiles and asthma. However, the causal association is unknown. Therefore, this study investigated the causal relationship between blood lipid profiles and asthma using bidirectional Mendelian randomization analysis.

METHODS AND MATERIALS

Our analyses were performed using individual data from the Taiwan Biobank and summary statistics from the Asian Genetic Epidemiology Network (AGEN). The causal estimates between all genetic variants, exposures of interest and asthma were calculated using an inverse-variance weighted method based on Taiwan Biobank data from 24,853 participants (mean age, 48.8 years; 49.8% women). Sensitivity analyses, including the weighted median, MR Egger regression, MR-PRESSO, mode-based estimate, contamination mixture methods, and leave-one-out analysis, were applied to validate the results and detect pleiotropy.

RESULTS

In the inverse-variance weighted (IVW) analyses, we found evidence of a significant causal effect of an increased level of low-density lipoprotein cholesterol on asthma risk (βIVW = 1.338, p = 0.001). A genetically decreased level of high-density lipoprotein cholesterol was also associated with asthma risk (βIVW = -0.338, p = 0.01). We also found that an increased level of total cholesterol was associated with an increased risk of asthma (βIVW = 1.343, p = 0.001). Several sensitivity analyses generated consistent findings. We did not find evidence to support the causality between asthma and blood lipid profiles in either direction.

CONCLUSION

Our results supported the causal relationship between higher levels of LDL cholesterol and total cholesterol and lower levels of HDL cholesterol with an increased risk of asthma.

Benralizumab efficacy and safety in severe asthma: A randomized trial in Asia

BACKGROUND

Benralizumab is indicated as add-on therapy in patients with uncontrolled, severe eosinophilic asthma; it has not yet been evaluated in a large Asian population with asthma in a clinical trial.

OBJECTIVE

To evaluate the efficacy and safety of benralizumab in patients with severe asthma in Asia.

METHODS

MIRACLE (NCT03186209) was a randomized, Phase 3 study in China, South Korea, and the Philippines. Patients aged 12-75 years with severe asthma receiving medium-to-high-dose inhaled corticosteroid/long-acting β2-agonists, stratified (2:1) by baseline blood eosinophil count (bEOS) (≥300/μL; <300/μL), were randomized (1:1) to benralizumab 30 mg or placebo. Endpoints included annual asthma exacerbation rate (AAER; primary endpoint), change from baseline at Week 48 in pre-bronchodilator (BD) forced expiratory volume in 1 second (pre-BD FEV1) and total asthma symptom score (TASS). Safety was evaluated ≤ Week 56.

RESULTS

Of 695 patients randomized, 473 had baseline bEOS ≥300/μL (benralizumab n = 236; placebo n = 237). In this population, benralizumab significantly reduced AAER by 74% (rate ratio 0.26 [95% CI 0.19, 0.36], p < 0.0001) and significantly improved pre-BD FEV1 (least squares difference [LSD] 0.25 L [95% CI 0.17, 0.34], p < 0.0001) and TASS (LSD -0.25 [-0.45, -0.05], p = 0.0126) versus placebo. In patients with baseline bEOS <300/μL, there were numerical improvements in AAER, pre-BD FEV1, and TASS with benralizumab versus placebo. The frequency of adverse events was similar for benralizumab (76%) and placebo (80%) in the overall population.

CONCLUSIONS

MIRACLE data reinforces the efficacy and safety of benralizumab for severe eosinophilic asthma in an Asian population, consistent with the global Phase 3 results.

Analyzing COVID-19 and Air Pollution Effects on Pediatric Asthma Emergency Room Visits in Taiwan

(1) Background: An asthma exacerbation that is not relieved with medication typically requires an emergency room visit (ERV). The coronavirus disease 2019 (COVID-19) pandemic began in Taiwan in January of 2020. The influence of the COVID-19 pandemic on pediatric ERVs in Taiwan was limited. Our aim was to survey pediatric asthma ERVs in the COVID-19 era; (2) Methods: Data were collected from the health quality database of the Taiwanese National Health Insurance Administration from 2019 to 2021. Air pollution and climatic factors in Taipei were used to evaluate these relationships. Changes in the rates of pediatric asthma ERVs were assessed using logistic regression analysis. Poisson regression was used to evaluate the impact of air pollution and climate change; (3) Results: The rate of pediatric asthma ERVs declined in different areas and at different hospital levels including medical centers, regional and local hospitals. Some air pollutants (particulate matter ≤ 2.5 µm, particulate matter ≤ 10 µm, nitrogen dioxide, and carbon monoxide) reduced during the COVID-19 lockdown. Ozone increased the relative risk (RR) of pediatric asthma ERVs during the COVID-19 period by 1.094 (95% CI: 1.095-1.12) per 1 ppb increase; (4) Conclusions: The rate of pediatric asthma ERVs declined during the COVID-19 pandemic and ozone has harmful effects. Based on these results, the government could reduce the number of pediatric asthma ERVs through healthcare programs, thereby promoting children's health.

Short-Term Exposure Effect of Ambient Fine Particulate Matter, Ozone and Cold Temperature on Emergency Room Visits for Asthma Patients

(1) Background: The acute effects of ozone, cold temperature and particulate matter less than 2.5 μm (PM_2.5) in size related to asthma attacks are well known worldwide. The adverse effects of ozone and cold temperature on asthma morbidity in Taiwan are still inconclusive. (2) Methods: This retrospective study included patients who had asthma emergency room visits (ERVs) from 1 January 2016 to 31 December 2019 in a regional hospital in Taiwan. The short-term negative effects were estimated using Distributed Lag Non-Linear Models (DLNMs) for the relative risks (RRs) of asthma ERVs associated with PM_2.5, ozone and cold temperature exposures within 5 days. (3) Results: There was a significant association between a 10 ppm increase in PM_2.5 exposure and asthma ERVs at a 2-day lag (RR 1.166, 95% confidence interval (C.I.): 1.051-1.294). There was a significant association between ozone and asthma ERVs at a 1-day lag (RR 1.179, 95% C.I.: 1.034-1.345). The ambient temperature in cold weather compared with the temperature of minimum asthma ERV showed an RR of 1.214, 95% C.I.: 1.009-1.252 at a 1-day lag. (4) Conclusions: This study provides evidence that short-term exposure to fine suspended particulates, ozone and inverse temperature is associated with asthma exacerbation.

Effects of oligo-fucoidan on the immune response, inflammatory status and pulmonary function in patients with asthma: a randomized, double-blind, placebo-controlled trial

Asthma is a common disease occurring worldwide. The clinical treatment of asthma is constantly revised and updated; however, it is associated with side effects. Our previous in vitro and ex vivo studies found that oligo-fucoidan can improve allergic immune responses and reduce airway inflammation. The purpose of this clinical trial was to investigate the effects of oligo-fucoidan on the immune status, inflammatory response, and pulmonary function of patients with asthma. Twenty asthmatic patients were randomly divided into two groups: (1) control group: receiving regular asthma treatment and supplementation with placebo; (2) fucoidan group: receiving regular asthma treatment and supplementation with oligo-fucoidan. Pulmonary function tests, the "Asthma Control Questionnaire" survey, biochemical data, inflammatory factors, and immune cell subtypes were detected. During treatment, the levels of WBC (p = 0.038) and creatinine (p = 0.012 and p = 0.008 at 12th and 24th weeks) were significantly decreased in the fucoidan group. Lung function (FEV₁/FVC pr) significantly increased in the fucoidan group (p = 0.046). Regarding the proportion of immune cells, the level of IFN⁺ and CD4⁺IFN⁺cells in the fucoidan group was significantly increased during the treatment period (P < 0.05), while the proportions of CD3⁺CD4⁺ cells (p = 0.048) and CD3⁺CD8⁺ cells (p = 0.009) in the fucoidan group were significantly decreased during the treatment period. Regarding cytokines, the level of interleukin-8 (IL-8) was also significantly reduced in the fucoidan group during the treatment period.

SABA prescriptions and asthma management practices in patients treated by specialists in Taiwan: Results from the SABINA III study

PURPOSE

Limited data exist on asthma medication patterns in Taiwan. The objectives of the SABINA III cross-sectional study in Taiwan were thus, to describe patient demographics and clinical features and estimate short-acting β₂-agonist (SABA) and inhaled corticosteroids (ICS) prescriptions per patient.

METHODS

Patients (≥18 years) with asthma were classified by investigator-defined asthma severity per the 2017 Global Initiative for Asthma (GINA) recommendations. Data on asthma symptom control (per GINA 2017 recommendations), severe exacerbation history, and prescribed treatments in the 12 months before study visit were collected using electronic case-report forms. Analyses were descriptive.

RESULTS

Overall, all 294 analyzed patients (mean [SD] age, 57.9 [15.6] years; female, 69%) were enrolled by specialists and had fully reimbursed healthcare. Most patients were classified with moderate-to-severe asthma (93.2%; GINA steps 3-5), were obese (53.4%) and nonsmokers (79.6%), reported high school or university and/or postgraduate education (61.9%), and had ≤2 comorbidities (89.1%). Mean (SD) asthma duration was 8.3 (10.0) years, with 37.8% of patients experiencing ≥1 severe exacerbation 12 months before the study visit. Overall, 62.2%, 26.2%, and 11.6% of patients had well-controlled, partly controlled, and uncontrolled asthma, respectively. Crucially, 19.3% of patients were prescribed ≥3 SABA canisters in the preceding 12 months (overprescription). ICS, ICS + long-acting β_2-agonist fixed-dose combination, and oral corticosteroid bursts were prescribed to 6.5%, 97.3%, and 31.6% of patients, respectively.

CONCLUSION

Despite treatment by specialists and fully reimbursed healthcare, findings indicate room for improvement in asthma control and SABA prescription practices in Taiwan, emphasizing the need to adhere to latest evidence-based guidelines.

Higher Risk of Hyperthyroidism in People with Asthma: Evidence from a Nationwide, Population-Based Cohort Study

BACKGROUND

Studies have indicated that hyperthyroidism exacerbates asthma; however, the influence of asthma in the development of hyperthyroidism has not been adequately studied.

OBJECTIVE

The aim of this population-based, retrospective cohort study was to investigate the association between asthma and the development of hyperthyroidism.

METHODS

In this retrospective cohort study, datasets from the Longitudinal Health Insurance Database 2000 in Taiwan during 1997 to 2013 were retrieved. Patients newly diagnosed with asthma (International Classification of Diseases, Ninth Revision: 493) during 2000 to 2013 were identified as the exposure cohort. The 1:1 propensity-score-matched nonasthma individuals were selected as the comparison cohort. The hazard ratio (HR) of development of hyperthyroidism in patients with asthma and its association with age and follow-up time were examined.

RESULTS

A total of 45,182 individuals were included in the study, including 22,591 and 22,591 patients with (asthma group) and without (control group) asthma, respectively. Incidence rates (per 100,000 person-months) of hyperthyroidism in the study groups were 12.88 in the control group and 16.95 in the asthma group. The adjusted HR for developing hyperthyroidism was 1.31 (95% confidence interval, 1.12-1.53) in patients with asthma compared with controls. The risk of developing hyperthyroidism was higher in patients with asthma aged>30 years old and with a follow-up of <3 years than in other subgroups.

CONCLUSION

Patients with asthma had a higher risk of developing hyperthyroidism, especially those over 30 years of age and in the first 3 years after diagnosis of asthma. Clinicians caring for patients with asthma should be aware of this increased risk.

Comparing Patient Characteristics, Clinical Outcomes, and Biomarkers of Severe Asthma Patients in Taiwan

PURPOSE

To understand the association between biomarkers and exacerbations of severe asthma in adult patients in Taiwan.

MATERIALS AND METHODS

Demographic, clinical characteristics and biomarkers were retrospectively collected from the medical charts of severe asthma patients in six hospitals in Taiwan. Exacerbations were defined as those requiring asthma-specific emergency department visits/hospitalizations, or systemic steroids. Enrolled patients were divided into: (1) those with no exacerbations (non-exacerbators) and (2) those with one or more exacerbations (exacerbators). Receiver operating characteristic curves were used to determine the optimal cut-off value for biomarkers. Generalized linear models evaluated the association between exacerbation and biomarkers.

RESULTS

132 patients were enrolled in the study with 80 non-exacerbators and 52 exacerbators. There was no significant difference in demographic and clinical characteristics between the two groups. Exacerbators had significantly higher eosinophils (EOS) counts (367.8 ± 357.18 vs. 210.05 ± 175.24, p = 0.0043) compared to non-exacerbators. The optimal cut-off values were 292 for EOS counts and 19 for the Fractional exhaled Nitric Oxide (FeNO) measure. Patients with an EOS count ≥ 300 (RR = 1.88; 95% CI, 1.26-2.81; p = 0.002) or FeNO measure ≥ 20 (RR = 2.10; 95% CI, 1.05-4.18; p = 0.0356) had a significantly higher risk of exacerbation. Moreover, patients with both an EOS count ≥ 300 and FeNO measure ≥ 20 had a significantly higher risk of exacerbation than those with lower EOS count or lower FeNO measure (RR = 2.16; 95% CI, 1.47-3.18; p = < 0.0001).

CONCLUSIONS

Higher EOS counts and FeNO measures were associated with increased risk of exacerbation. These biomarkers may help physicians identify patients at risk of exacerbations and personalize treatment for asthma patients.

Association of Traumatic Injury With Adverse Pregnancy Outcomes in Taiwan, 2004 to 2014

IMPORTANCE

Literature has suggested that trauma among pregnant women is associated with an increased risk of adverse pregnancy outcomes. However, limited research has investigated the association of trauma with adverse pregnancy outcomes by using a national data set.

OBJECTIVE

To investigate the association between traumatic injury and adverse pregnancy outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study of pregnant women in Taiwan linked 3 data sets, the Taiwan Birth Registry, Household Registration Information, and National Health Insurance Research Database, from January 1, 2004, through December 31, 2014. Data, including the characteristics of pregnant women and infants, were extracted from the Taiwan Birth Registry data set; to obtain trauma data, this data set and the Household Registration Information data set were collectively linked to National Health Insurance Research Database data. The combined data set was analyzed from January to July 2019. Adverse pregnancy outcomes and premature delivery were defined using International Classification of Diseases, Ninth Revision, Clinical Modification codes.

EXPOSURES

The primary exposures of this study were 2 clinical variables related to injury during pregnancy: medical treatment in the emergency department (yes or no) and hospitalization (yes or no).

MAIN OUTCOMES AND MEASURES

The main outcome variable was adverse pregnancy outcomes, and the secondary outcome variable was premature delivery. Multivariate logistic regression models were used to investigate the association of injuries with adverse pregnancy outcomes after controlling for demographic characteristics and other pregnancy-related variables.

RESULTS

A total of 2 973 831 pregnant women (2 475 805 [83.3%] aged 20-34 years) were enrolled between 2004 and 2014, of whom 59 681 (2.0%) sought medical treatments due to injuries. Results of multivariate logistic regression models showed that women receiving emergency treatments more than once were 1.08 times as likely (adjusted odds ratio, 1.08; 95% CI, 1.05-1.10) to have adverse pregnancy outcomes than women who received no emergency treatment. Women with injury-related hospitalization were 1.53 times more likely (adjusted odds ratio, 1.53; 95% CI, 1.41-1.65) to have adverse pregnancy outcomes than women who did not sustain injuries. Furthermore, recurrent injuries were associated with a 572% increase in odds of premature delivery (adjusted odds ratio, 6.72; 95% CI, 2.86-15.80).

CONCLUSIONS AND RELEVANCE

In this study, trauma among pregnant women was associated with an increased risk of adverse pregnancy outcomes, as were hospitalization and emergency department visits due to injury.

A Multifactorial Evaluation of the Effects of Air Pollution and Meteorological Factors on Asthma Exacerbation

In the real world, dynamic changes in air pollutants and meteorological factors coexist simultaneously. Studies identifying the effects of individual pollutants on acute exacerbation (AE) of asthma may overlook the health effects of the overall combination. A comprehensive study examining the influence of air pollution and meteorological factors is required. Asthma AE data from emergency room visits were collected from the Taiwan National Health Insurance Research Database. Complete monitoring data for air pollutants (SO₂; NO₂; O₃; CO; PM_2.5; PM₁₀) and meteorological factors were collected from the Environmental Protection Agency monitoring stations. A bi-directional case-crossover analysis was used to investigate the effects of air pollution and meteorological factors on asthma AE. Among age group divisions, a 1 °C temperature increase was a protective factor for asthma ER visits with OR = 0.981 (95% CI, 0.971–0.991) and 0.985 (95% CI, 0.975–0.994) for pediatric and adult patients, respectively. Children, especially younger females, are more susceptible to asthma AE due to the effects of outdoor air pollution than adults. Meteorological factors are important modulators for asthma AE in both asthmatic children and adults. When studying the effects of air pollution on asthma AE, meteorological factors should be considered.

Knowledge, Attitude, and Practice of Yoga in Rural and Urban India, KAPY 2017: A Nationwide Cluster Sample Survey

Background: To examine the knowledge, attitudes, and practice gap of yoga across India based on implicit perceptions. Methods: The present study is a nationwide door-to-door survey conducted using a questionnaire/screening form. The data were collected from a national survey conducted under the Niyantrit Madhumeh Bharat (NMB) program initiated by The Ministry of Ayurveda, Yoga, Unani, Siddha, Homeopathy (AYUSH), Government of India, from all major zones of the country. A total of 162,330 participants who joined the NMB program were recruited in our study. Results: Out of the total respondents to the survey, it was observed that 11.8% [13,336/112,735] practice yoga, which was highest in the north zone [4,567/112,735] and lowest in the east zone [971/112,735]. Out of 101,643 respondents, 94,135 of the individuals who participated in the survey believed that yoga improved their lifestyle, and 90,102/98,518 believed that yoga prevented diabetes, revealing a huge knowledge–practice gap. Conclusions: The scale of the knowledge–practice gap coupled with the general acceptability of yoga calls for a change in the conventional healthcare provisions by its integration with modern medicine. The population-wide positive perceptions about yoga as a preventive health tool can not only catalyze consensus disease-specific yoga modules but also bridge the knowledge–practice gap that exists because of limited yoga centers and professionals.

Current situation of asthma-COPD overlap in Chinese patients older than 40 years with airflow limitation: a multicenter, cross-sectional, non-interventional study

BACKGROUND AND AIMS

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is poorly recognized in China. Our study determined the distribution of ACO and its clinical characteristics among patients (aged ⩾40 years) with airflow limitation at Chinese tertiary hospitals.

METHODS

This cross-sectional, non-interventional study (NCT02600221), conducted between December 2015 and October 2016 in 20 Tier-3 Chinese hospitals, included patients aged ⩾40 years with post-bronchodilator (BD) FEV1/FVC <0.7. The primary variable was distribution of ACO in adults with post-BD forced expiratory volume /forced vital capacity (FEV1/FVC) <0.7 based on Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015 and 2017 reports. Other variables included determination of characteristics of ACO and its clinical recognition rate.

RESULTS

In 2003 patients (mean age 62.30 ± 9.86 years), distribution of ACO, COPD and asthma were 37.40%, 48.50% and 14.10%, respectively. Proportions of patients with A, B, C and D grouping were 11.70%, 31.00%, 6.90% and 50.30% as per GOLD 2017, whereas they were 15.10%, 51.10%, 3.60% and 30.20% as per GOLD 2015. Similar clinical symptoms were reported in all three groups. A higher percentage of ACO patients presented with dyspnea, wheezing and chest tightness. Compared with the COPD group, a greater proportion of ACO patients reported wheezing (74.6% and 65.40%), while a lower proportion in the ACO group reported cough (79.40% versus 82.70%) and expectoration (76.50% versus 81.60%). Blood eosinophil count ⩾0.3 × 109/L was observed in 34.6% of ACO patients. The clinical recognition rate of ACO was 31.4%.

CONCLUSION

Despite ACO affecting two-fifths of the study population, the initial diagnosis rate was low at 6% in China, thus warranting concerted efforts to improve ACO diagnosis.

CLINICALTRIALS.GOV

[ClinicalTrials.gov identifier: NCT02600221] registered 22 October 2015, https://clinicaltrials.gov/ct2/show/NCT02600221The reviews of this paper are available via the supplemental material section.

Trends and regional distribution of outpatient claims for asthma, 2009-2016, Germany

OBJECTIVE

To investigate asthma morbidity in Germany by calculating current prevalence, examining its temporal and spatial trends and estimating the total number of asthmatics in Germany and calculating age-, sex- and residence-specific risk.

METHODS

We used claims data reported by physicians during 2009-2016, including outpatient diagnoses of all statutory health insured individuals, comprising 85.3% (70 416 019/82 521 653) of the total population in Germany in 2016. We performed a spatial analysis of asthma prevalence according to administrative district by calculating Global and Local Moran's I. We assessed the risk of asthma by sex, age, type of residence (rural versus urban) and federal state (East versus West) using a multilevel parametric survival regression.

FINDINGS

We estimated that 4.7 million individuals were affected by asthma in 2016, including 0.8 million children and 3.9 million adults. We observed a slightly higher prevalence (with an increasing trend) among adults (5.85%; 3 408 622/58 246 299) compared to children (5.13%; 624 899/12 169 720), and calculated an age-standardized prevalence of 5.76% (95% confidence interval, CI: 5.76-5.77). We found evidence of a strong spatial autocorrelation (Global Moran's I: 0.50, P < 0.0001), and identified local spatial clusters with higher levels of prevalence. Living in the western (versus eastern) federal states and living in densely populated large urban municipalities (versus rural area) were independently associated with an increased risk of asthma, with hazard ratios of 1.33 (95% CI: 1.32-1.34) and 1.32 (95% CI: 1.31-1.32), respectively.

CONCLUSION

Our insights into the spatial distribution of asthma morbidity may inform public health interventions, including region-specific prevention programmes and control.

Is asthma a protective factor for dengue fever? In vitro experiment and nationwide population-based cohort analysis

BACKGROUND

Dengue fever (DF) is the most rapidly spreading mosquito-borne viral disease. Practical vaccines or specific therapeutics are still expected. Environmental factors and genetic factors affect the susceptibility of Dengue virus (DV) infection. Asthma is a common allergic disease, with house dust mites (HDMs) being the most important allergens. Asthmatic patients are susceptible to several microorganism infections.

METHODS

A nationwide population-based cohort analysis was designed to assess whether to determine whether asthma can be a risk factor for DF.

RESULTS

Unexpectedly, our data from a nationwide population-based cohort revealed asthmatic patients are at a decreased risk of DF. Compared to patients without asthma, the hazard ratio (HR) for DF in patients with asthma was 0.166 (95% CI: 0.118-0.233) after adjustment for possible confounding factors. In the age stratification, the adjusted HR for DF in young adult patients with asthma was 0.063. Dendritic cell-specific intercellular adhesion molecule 3-grabbing non-integrin (DC-SIGN) of dendritic cells (DCs) is an important entry for DV. Through another in vitro experiment, we found that HDM can diminish surface expression of DC-SIGN in monocyte-derived DCs and further decrease the cellular entry of DV.

CONCLUSIONS

Decreased DC-SIGN expression in DCs of allergic asthmatic patient may be one of many factors for them to be protected against DF. This could implicate the potential for DC-SIGN modulation as a candidate target for designing therapeutic strategies for DF.

National retrospective cohort study to identify age-specific fatality risks of comorbidities among hospitalised patients with influenza-like illness in Taiwan

OBJECTIVES

This study aimed to examine comprehensively the prognostic impact of underlying comorbidities among hospitalised patients with influenza-like illness (ILI) in different age groups and provide recommendations targeting the vulnerable patients.

SETTING AND PARTICIPANTS

A retrospective cohort of 83 227 hospitalised cases with ILI were identified from Taiwan's National Health Insurance Research Database from January 2005 to December 2010. Cases were stratified into three different age groups: paediatric (0-17 years), adult (18-64 years) and elderly (≧65 years), and their age, sex, comorbidity and past healthcare utilisation were analysed for ILI-associated fatality.

MAIN OUTCOME MEASURES

ORs for ILI-related fatality in different age groups were performed using multivariable analyses with generalised estimating equation models and adjusted by age, sex and underlying comorbidities.

RESULTS

Hospitalised ILI-related fatality significantly increased with comorbidities of cancer with metastasis (adjusted OR (aOR)=3.49, 95% CI: 3.16 to 3.86), haematological malignancy (aOR=3.02, 95% CI: 2.43 to 3.74), cancer without metastasis (aOR=1.72, 95% CI: 1.54 to 1.91), cerebrovascular (aOR=1.24, 95% CI: 1.15 to 1.33) and heart diseases (aOR=1.19, 95% CI: 1.11 to 1.27) for all age groups. Adult patients with AIDS; adult and elderly patients with chronic kidney disease, tuberculosis and diabetes were significantly associated with elevated risk of death. Severe liver diseases and hypothyroidism among elderly, and dementia/epilepsy among elderly and paediatrics were distinctively associated with likelihood of ILI-related fatality.

CONCLUSIONS

Different age-specific comorbidities were associated with increasing risk of death among hospitalised ILI patients. These findings may help update guidelines for influenza vaccination and other prevention strategies in high-risk groups for minimising worldwide ILI-related deaths.

Oligo-fucoidan improved unbalance the Th1/Th2 and Treg/Th17 ratios in asthmatic patients: An ex vivo study

An imbalance in the helper T cells (Th)1/Th2 and regulatory T cells (Tregs)/Th17 ratios is believed to play a key role in asthmatic inflammatory responses. Fucoidan reportedly reduces the production of inflammatory factors. Nutritional intervention is an important tool in decreasing the severity of asthmatic disease. This study aimed to investigate the beneficial roles of oligo-fucoidan in balancing the T cell subtype ratios and reducing airway inflammation ex vivo. Peripheral blood mononuclear cells (PBMCs) were collected from 30 asthmatic subjects and 15 healthy subjects. Harvested PBMCs were stimulated and treated with or without oligo-fucoidan (100 or 500 µg/ml) for 48 h. Cell surface and intracellular cytokine markers were examined by flow cytometry. The pro-inflammatory factors in plasma and culture supernatants were measured using ELISA kits. We found that oligo-fucoidan increases the proportion of Th1 and Treg cells, but did not affect the proportion of Th2 and Th17 cells. Oligo-fucoidan also increased the levels of interferon-γ and interleukin-10. Thus, we concluded that oligo-fucoidan might improve the imbalance in Th1/Th2 and Treg/Th17 ratios to reduce airway inflammation, which could be a potential adjuvant therapy for allergic asthma.

Changing patterns of adult asthma incidence: results from the National Health Insurance Service-National Sample Cohort (NHIS-NSC) database in Korea

This study was conducted to assess the changes in the annual incidence of adult asthma in Korea where the prevalence of asthma had increased steadily in recent decades. A population-based cohort study was conducted using the National Health Insurance Service–National Sample Cohort (NHIS-NSC), which consisted of 746,816 adults aged >20 years between 2004 and 2012. Asthma was defined by two or more physician claims on the basis of a primary diagnostic code for asthma and administration of asthma medications within 1 year. The incidence rates and annual percent change were calculated, and the influence of age and sex on the incidence rates was studied. The annual asthma incidence increased from 3.63 in 2004 to 6.07 per 1,000 person-years in 2008. Since 2008, the asthma incidence did not change significantly. The asthma incidence was higher in women than in men throughout the study periods (p < 0.001) and higher in older than younger age groups (p < 0.001). The asthma incidence did not change in all ages since 2008, except for the 20 s who showed a steady increase. The incidence of asthma in adults reached plateau in Korea, which is consistent with the results from studies in other countries.

Comparative efficacy and tolerability of beclomethasone/formoterol and fluticasone/salmeterol fixed combination in Taiwanese asthmatic patients

BACKGROUND

The study was designed to compare the efficacy and tolerability of a fixed combination of extra-fine beclomethasone and formoterol, with the fixed combination fluticasone and salmeterol in Taiwanese asthmatic patients.

METHODS

This was a phase III, multicentre, randomized, two-arm parallel groups, controlled study. Patients with moderate to severe asthma were randomized to a 12-week treatment with either beclomethasone 100 mcg plus formoterol 6 mcg (BDP/F) or fluticasone 125 mcg plus salmeterol 25 mcg (FP/S), both delivered 2 inhalations twice daily. The efficacy and tolerability of these two combinations were compared.

RESULTS

Among the 253 randomized subjects, 244 patients were evaluable (119 in the BDP/F group and 125 in the FP/S group). A significant improvement from baseline to the end of treatment period was observed in both BDP/F and FP/S groups in forced expiratory volume in the first second (FEV₁), forced vital capacity (FVC), morning and evening peak expiratory flow (PEF), Asthma Control Test (ACT) score and the use of rescue medication. FVC increase from pre-dose was significant after 5 min post inhalation in the BDP/F group only, while statistically significant within group improvement was not achieved until 30 min post inhalation in the FP/S group.

CONCLUSION

The BDP/F combination is comparable in efficacy and tolerability to FP/S combination in Taiwanese asthmatic patients, with the advantage of rapid onset of improvement of FVC, consistent with the faster improvement of pulmonary hyperinflation with BDP/F.

Using medication utilization information to develop an asthma severity classification model

Background

Claims data are currently widely used as source data in asthma studies. However, the insufficient information in claims data related to level of asthma severity may negatively impact study findings. The present study develops and validates an asthma severity classification model that uses medication utilization in Taiwan National Health Insurance claims data.

Methods

The National Health Insurance Research Database was used for the years 2006–2012 and included a total of 7221 patients newly diagnosed with asthma in 2007 for model development and in 2008 for model validation. The medication utilization of patients during the first year after the index date was used to classify level of severity, and the acute exacerbation of asthma during the second through fourth years after the index date was used as the outcome variable. Three models were developed, with subjects classified into four, three, and two groups, respectively. The area under the receiver operating characteristic curve (AUC) and the Kaplan-Meier survival curve were used to compare the performances of the classification models.

Results

In development data, the distribution of subjects and acute exacerbation rate among the stage 1 to stage 4 were: 62.71%, 5.54%, 22.79%, and 8.96%, and 8.17%, 9.55%, 11.97%, and 14.91%, respectively. The results also showed the higher severity groups to be more prone to being prescribed oral corticosteroids for asthma control, while lower severity groups were more likely to be prescribed short-acting medication and inhaled corticosteroid treatment. Furthermore, the results of survival analysis showed two-group classification was recommended and yield moderate performance (AUC = 0.671). In validation data, the distribution of subjects, acute exacerbation rates, and medication uses among stages were similar to those in development data, and the results of survival analysis were also the same.

Conclusions

Understanding asthma severity is critical to conducting effective, scholarly research on asthma, which currently uses claims data as a primary data source. The model developed in the present study not only overcomes a gap in the current literature but also provides an opportunity to improve the validity and quality of claims-data-based asthma studies.

Effect of enterovirus infections on asthma in young children: A national cohort study

BACKGROUND

We conducted a cohort study to determine the relationship between enterovirus (EV) infection and asthma.

MATERIALS AND METHODS

From the National Health Insurance Research Database of Taiwan, we identified patients who received a new diagnosis of asthma and concurrent treatment between January 2000 and December 2011 (EV cohort: n = 208 213; non-EV cohort: n = 208 213). Cox proportional hazards regression analysis was performed to determine and compare the adjusted hazard ratios (aHRs) of asthma between these 2 cohorts. Kaplan-Meier analysis was conducted to assess the differences in the cumulative incidence curves of asthma between the 2 cohorts.

RESULTS

The overall aHR of asthma was 1.48-fold higher in the EV cohort than in the non-EV cohort (95% confidence interval = 1.45-1.50). The aHR of asthma was higher in the EV cohort than in the non-EV cohort, comprising children aged ≤5 years, regardless of sex, sociodemographic factors (urbanization level and parental occupation) or comorbidities. The risk of asthma was higher in 1-3, 4-6, 7-9 and 10-12 months (all P < .001), particularly in those with a higher frequency of admission (>5 per year).

CONCLUSION

The incidence of asthma was higher in the EV cohort than in the non-EV cohort, comprising children aged ≤5 years, regardless of sex, urbanization level, parental occupation or season. In particular, the risk of asthma was higher in children with a higher frequency of admission, even in the absence of atopy or other respiratory infections.

Models for estimating and projecting global, regional and national prevalence and disease burden of asthma: protocol for a systematic review

INTRODUCTION

Models that have so far been used to estimate and project the prevalence and disease burden of asthma are in most cases inadequately described and irreproducible. We aim systematically to describe and critique the existing models in relation to their strengths, limitations and reproducibility, and to determine the appropriate models for estimating and projecting the prevalence and disease burden of asthma.

METHODS

We will search the following electronic databases to identify relevant literature published from 1980 to 2017: Medline, Embase, WHO Library and Information Services and Web of Science Core Collection. We will identify additional studies by searching the reference list of all the retrieved papers and contacting experts. We will include observational studies that used models for estimating and/or projecting prevalence and disease burden of asthma regarding human population of any age and sex. Two independent reviewers will assess the studies for inclusion and extract data from included papers. Data items will include authors' names, publication year, study aims, data source and time period, study population, asthma outcomes, study methodology, model type, model settings, study variables, methods of model derivation, methods of parameter estimation and/or projection, model fit information, key findings and identified research gaps. A detailed critical narrative synthesis of the models will be undertaken in relation to their strengths, limitations and reproducibility. A quality assessment checklist and scoring framework will be used to determine the appropriate models for estimating and projecting the prevalence anddiseaseburden of asthma.

ETHICS AND DISSEMINATION

We will not collect any primary data for this review, and hence there is no need for formal National Health Services Research Ethics Committee approval. We will present our findings at scientific conferences and publish the findings in the peer-reviewed scientific journal.

STROBE-compliant article: Is continuity of care associated with avoidable hospitalization among older asthmatic patients?

Continuity of care (COC) has a proven relationship with health care outcomes. However, evidence regarding an association between COC and avoidable hospitalization for elderly patients with asthma is insufficient.A retrospective cohort study was performed using Taiwanese National Health Insurance claim data from 2004 to 2013. Patients were retrospectively followed for 2 years; the COC index (COCI) for asthma was measured in the 1st year, and avoidable hospitalization for asthma and follow-up time were determined in the subsequent year. Cox proportional hazards regression was employed to examine hazard ratios (HRs) between COC and avoidable hospitalization for asthma after adjustment for confounding factors. Adjusted HR (aHR) was also calculated by stratifying each variable to investigate whether the effect of COC on hospitalization for asthma was avoidable and how this varied across levels of COCI.Of 3356 patients included in this study, 1648 patients (49%) had a COCI of 1, and the average COCI was 0.73. Compared with patients with high COC (COCI = 1), those with low COC (COCI < 0.5) had a significantly higher risk of avoidable hospitalization for asthma (aHR = 2.68; 95% confidence interval [CI]: 1.55-4.63). In addition, after stratified analysis, we determined that COC plays a much more important role for patients who were women, had low insurance premiums, and had no comorbidities.High continuity of ambulatory asthma care is linked to a reduced risk of avoidable hospitalization for asthma in elderly asthmatic patients.