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Bourdin A, Chupp G, Jackson DJ, Cohen D, Emerath U, Shavit A, Kurdyukova Y, Menzies-Gow A. MELTEMI and COLUMBA: 5-Year Comparative Safety Analysis of Benralizumab and Mepolizumab. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00418-5. [PMID: 38677588 DOI: 10.1016/j.jaip.2024.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Benralizumab and mepolizumab are interleukin (IL)-5Rα/interleukin-5-targeted monoclonal antibodies indicated as add-on treatments for patients with uncontrolled severe eosinophilic asthma (SEA). OBJECTIVE To evaluate and compare the safety of benralizumab and mepolizumab among patients with SEA treated in MELTEMI and COLUMBA open-label, long-term extension studies, respectively. METHODS MELTEMI was an extension study of benralizumab every 4 weeks (q4w) or every 8 weeks (q8w) for adults (aged 18-75 y) with SEA. MELTEMI participants transitioned from the BORA extension, preceded by participation in 1 of 3 placebo-controlled studies (SIROCCO, CALIMA, or ZONDA). COLUMBA was an extension study of mepolizumab for patients (aged ≥ 12 y) with SEA who transitioned from the dose-ranging DREAM study. Safety endpoints were presented as drug exposure patient-years (MELTEMI, q4w 784.28, q8w 797.03; COLUMBA 1,201) for nonserious adverse events, serious adverse events, and infections; malignancies were counted numerically. RESULTS This analysis included 446 MELTEMI patients (benralizumab q4w 220; benralizumab q8w 226) and 347 COLUMBA patients (mepolizumab q4w). Viral upper respiratory tract infection was the most common nonserious adverse event in both studies (MELTEMI q8w 46.5%; q4w 47.3%; COLUMBA, 48.7%). Asthma-related events were the most common serious adverse events in both studies: MELTEMI 8.0% (q8w) and 8.6% (q4w) and COLUMBA 9.5%. Serious infections included pneumonia (MELTEMI q8w, 2 [0.9%]; COLUMBA, 6 [1.7%]); cellulitis (MELTEMI q8w, 1 [0.4%]; COLUMBA, 2 [0.6%]); and respiratory tract infections (COLUMBA, 2 [0.6%]). COLUMBA reported 6 malignancies and MELTEMI reported 4 malignancies in each group. CONCLUSIONS This analysis demonstrated generally similar safety events between mepolizumab and benralizumab in patients with SEA.
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Affiliation(s)
- Arnaud Bourdin
- Université de Montpellier, CHU Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France.
| | | | - David J Jackson
- Guy's Severe Asthma Centre, Guy's and St. Thomas' NHS Trust, London, UK; School of Immunology and Microbial Sciences, King's College London, London, UK
| | - David Cohen
- BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Md
| | - Ulrika Emerath
- Biopharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - Anat Shavit
- Biopharmaceuticals Medical, Respiratory and Immunology, AstraZeneca, Cambridge, UK
| | | | - Andrew Menzies-Gow
- Biopharmaceuticals Medical, Respiratory and Immunology, AstraZeneca, Cambridge, UK
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Hou X, Luo W, Gan H, Chen T, Sun B. Childhood blood eosinophils and symptoms of allergic disorders: a cross-sectional study in Southern China. Ann Med 2022; 54:2929-2940. [PMID: 36259652 PMCID: PMC9586638 DOI: 10.1080/07853890.2022.2134584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The relationship between childhood blood eosinophils and subtypes of allergic diseases remains understudied. This study aimed to examine the associations between childhood blood eosinophils and subtypes of asthma, rhinitis and dermatitis, as well as the modifying effect of age. METHODS We obtained concurrent blood cell counts and serum Immunoglobulin E (IgE) test results in 5026 children (0-13, years) from First Affiliated Hospital of Guangzhou Medical University from 2014 to 2019. Generalized additive models with multivariable adjustments were utilized to model the exposure-response relationship between eosinophils and allergic symptoms. The robustness of the association was assessed in two age categories (<6, 6-13 years). RESULTS The association of eosinophils with allergic asthma/rhinitis was positively nonlinear, with a plateau at levels of Q4 (≥0.51, 109/L). Conversely, exposure-response curves between eosinophils and the risk of non-allergic asthma and rhinitis were negatively linear, and especially, became statistically significant when levels of eosinophils were larger than Q3 (≥0.30, 109/L). Compared with their counterparts, school-aged children (6-13, years) with a higher level of blood eosinophils (≥0.35, 109/L) were more likely to suffer from allergic asthma [relative excess risk due to interaction (RERI), 2.51; 95% CI, 1.24-3.78], allergic rhinitis (RERI, 2.79; 95% CI, 1.14-4.45) but not allergic dermatitis (RERI not significant). CONCLUSION Higher eosinophil counts were associated with the increased risk of allergic subtype symptoms and the decreased risk of non-allergic subtypes in children. Moreover, the associations between eosinophils and allergic asthma/rhinitis were accentuated in the school-aged child. These findings may contribute to providing novel insights for clinical administration relevance of allergic-related symptoms.Key messages:There was a positively nonlinear association between childhood eosinophils and allergic asthma/rhinitis.Age modified the associations between eosinophils and allergy-related outcomes. The associations of eosinophil with allergic asthma/rhinitis accentuated in the school-aged child (6-13, years).
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Affiliation(s)
- Xiangqing Hou
- Faculty of Health Sciences, University of Macau, Macau, China
| | - Wenting Luo
- Department of Allergy and Clinical Immunology, State Key Laboratory of Respiratory Disease, National Clinical Research Center of Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangdong, China
| | - Hui Gan
- Department of Allergy and Clinical Immunology, State Key Laboratory of Respiratory Disease, National Clinical Research Center of Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangdong, China
| | - Tianhao Chen
- Faculty of Health Sciences, University of Macau, Macau, China
| | - Baoqing Sun
- Department of Allergy and Clinical Immunology, State Key Laboratory of Respiratory Disease, National Clinical Research Center of Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangdong, China
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Flokstra-de Blok B, Kocks J, Wouters H, Arling C, Chatelier J, Douglass J, Heaney LG, Holmes J, Humbert M, Kolanowski M, Landsman JJA, Lugogo N, Malpass A, Meijer J, Metz B, de Mul B, Postma F, Leving M. Perceptions on Home-Administration of Biologics in the Context of Severe Asthma: An International Qualitative Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2312-2323.e2. [PMID: 35487370 DOI: 10.1016/j.jaip.2022.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/05/2022] [Accepted: 04/11/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Biologics are an effective therapy for severe asthma. Home administration of biologics by patients is likely to facilitate their accessibility. Yet little is known about patients' and health care providers' (HCPs) perceptions regarding home administration of biologics. OBJECTIVE The aim of this study is to create more insight into the perceptions and experiences of patients and HCPs regarding home administration of biologics in the context of the treatment of severe asthma. METHODS A qualitative international study was performed in the Netherlands, United States, Australia, and United Kingdom. In each country, 2 focus groups were held with potential/recent and long-term users of biologics at home. Prior to the focus groups, patients were prompted with themes on online forums. For triangulation purposes, interviews were held with HCPs to discuss salient findings from forums and focus groups. Data were analyzed with qualitative content analysis. RESULTS In total, 75 patients participated in the forums, of which 40 participated in the focus groups. Furthermore, 12 HCPs were interviewed. The following overarching themes were identified: living with severe asthma; practical aspects of using biologics; the role of HCPs regarding biologics; social support from family, friends, and others; effectiveness of biologics and other treatments; side effects of biologics. CONCLUSIONS This study showed that, for those using biologics for severe asthma, the benefits of home administration of biologics usually outweigh inconvenience and side effects. Guided practice, accessible support contact, and monitoring including social support should be central in the transition from hospital to home administration of asthma biologics.
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Affiliation(s)
- Bertine Flokstra-de Blok
- General Practitioners Research Institute, Groningen, The Netherlands; Groningen Research Institute Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Pediatric Pulmonology and Pediatric Allergology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands.
| | - Janwillem Kocks
- General Practitioners Research Institute, Groningen, The Netherlands; Groningen Research Institute Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Observational and Pragmatic Research Institute, Singapore, Singapore; Department of Pulmonology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hans Wouters
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Chantal Arling
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Josh Chatelier
- Department of Medicine, The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Jo Douglass
- Department of Medicine, The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Liam G Heaney
- Wellcome Wolfson Centre for Experimental Medicine, Queens University, Belfast, Northern Ireland
| | - Joshua Holmes
- Wellcome Wolfson Centre for Experimental Medicine, Queens University, Belfast, Northern Ireland
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, INSERM UMR_S 999, Assistance Publique - Hôpitaux de Paris, Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Mary Kolanowski
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Mich
| | - Jeanet J A Landsman
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Njira Lugogo
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Mich
| | - Alice Malpass
- Bristol Medical School, Centre for Academic Primary Care (CAPC), University of Bristol, Bristol, UK
| | - Jiska Meijer
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Boyd Metz
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Bibicha de Mul
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Frank Postma
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Marika Leving
- General Practitioners Research Institute, Groningen, The Netherlands
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Singh S, Kumar P, Goyal JP, Singh K. Relationship of Peripheral Blood Counts with Asthma Control. Indian J Pediatr 2022; 90:555-559. [PMID: 35779231 DOI: 10.1007/s12098-022-04262-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/26/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To determine the association between blood eosinophil and neutrophil counts with asthma control. METHODS This retrospective study, conducted in tertiary care hospital of western India, evaluated the hospital electronic medical record (HEMR) of children aged 5 to 18 y who were diagnosed with asthma as per the Global Initiative for Asthma (GINA) guidelines in the pediatric chest clinic (PCC). Eosinophil and neutrophil counts were recorded from HEMR and asthma control was determined as per the GINA guidelines on follow-up. RESULTS A total of 742 children attended the PCC in the last 2 y from March 2017 to February 2019; out of which, blood eosinophil and neutrophil counts were done in 116 children with asthma. The median eosinophil and neutrophil count were 0.46 (0.13, 0.78) × 109/L and 5.08 (3.50, 7.53) × 109/L cells, respectively. Eosinophil count was significantly higher in children with well-controlled asthma as compared to partly/uncontrolled asthma [median eosinophil count 0.46 (0.13, 0.78) vs. 0.40 (0.1, 0.66) × 109/L; p = 0.04]; while the neutrophil count was significantly higher in children with partly/uncontrolled asthma as compared to well-controlled asthma [median neutrophil 6.54 (4.32, 7.92) vs. 4.85 (2.96, 6.86) × 109/L; p = 0.04]. CONCLUSIONS High lung function is associated with good asthma control. Although not independently associated, the high absolute eosinophil counts (AEC) is associated with better asthma control, while high absolute neutrophil counts (ANC) is associated with poor asthma control.
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Affiliation(s)
- Sachin Singh
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Prawin Kumar
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Jagdish Prasad Goyal
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India.
| | - Kuldeep Singh
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
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Kerkhof M, Tran TN, Allehebi R, Canonica GW, Heaney LG, Hew M, Perez de Llano L, Wechsler ME, Bulathsinhala L, Carter VA, Chaudhry I, Eleangovan N, Murray RB, Price CA, Price DB. Asthma Phenotyping in Primary Care: Applying the International Severe Asthma Registry Eosinophil Phenotype Algorithm Across All Asthma Severities. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:4353-4370. [PMID: 34403837 DOI: 10.1016/j.jaip.2021.07.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/15/2021] [Accepted: 07/31/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND We developed an eosinophil phenotype gradient algorithm and applied it to a large severe asthma cohort (International Severe Asthma Registry). OBJECTIVE We sought to reapply this algorithm in a UK primary care asthma cohort, quantify the eosinophilic phenotype, and assess the relationship between the likelihood of an eosinophilic phenotype and asthma severity/health care resource use (HCRU). METHODS Patients age 13 years and older with active asthma and blood eosinophil count or 1 or greater, who were included from the Optimum Patient Care Research Database and the Clinical Practice Research Datalink, were categorized according to the likelihood of eosinophilic phenotype using the International Severe Asthma Registry gradient eosinophilic algorithm. Patient demographic, clinical and HCRU characteristics were described for each phenotype. RESULTS Of 241,006 patients, 50.3%, 22.2%, and 21.9% most likely (grade 3), likely (grade 2), and least likely (grade 1), respectively, had an eosinophilic phenotype, and 5.6% had a noneosinophilic phenotype (grade 0). Compared with patients with noneosinophilic asthma, those most likely to have an eosinophilic phenotype tended to have more comorbidities (percentage with Charlson comorbidity index of ≥2: 28.2% vs 6.9%) and experienced more asthma attacks (percentage with one or more attack: 24.8% vs 15.3%). These patients were also more likely to have asthma that was difficult to treat (31.1% vs 18.3%), to receive more intensive treatment (percentage on Global Initiative for Asthma 2020 step 4 or 5: 44.2% vs 27.5%), and greater HCRU (eg, 10.8 vs 7.9 general practitioner all-cause consultations per year). CONCLUSIONS The eosinophilic asthma phenotype predominates in primary care and is associated with greater asthma severity and HCRU. These patients may benefit from earlier and targeted asthma therapy.
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Affiliation(s)
- Marjan Kerkhof
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom
| | | | - Riyad Allehebi
- Department of Pulmonology, King Fahad Medical City, Riyadh, Saudi Arabia
| | - G Walter Canonica
- Personalized Medicine Asthma and Allergy Clinic, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Liam G Heaney
- UK Severe Asthma Network and National Registry Centre and Centre for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Mark Hew
- Allergy, Asthma, and Clinical Immunology Service, Alfred Health, Melbourne, Australia; Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Luis Perez de Llano
- Department of Respiratory Medicine, Hospital Universitario Lucus Augusti, Lugo, Spain
| | - Michael E Wechsler
- NJH Cohen Family Asthma Institute, Department of Medicine, National Jewish Health, Denver, Colo
| | - Lakmini Bulathsinhala
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom
| | - Victoria A Carter
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom
| | - Isha Chaudhry
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom
| | - Neva Eleangovan
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom
| | - Ruth B Murray
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom
| | - Chris A Price
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom
| | - David B Price
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom; Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.
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6
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Tran TN, Kerkhof M, Carter V, Price DB. Persistence of Eosinophilic Asthma Endotype and Clinical Outcomes: A Real-World Observational Study. J Asthma Allergy 2021; 14:727-742. [PMID: 34211281 PMCID: PMC8242130 DOI: 10.2147/jaa.s306416] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 05/15/2021] [Indexed: 12/17/2022] Open
Abstract
Purpose Eosinophil count elevations are predictive of adverse outcomes in patients with asthma, yet little is known regarding longitudinal eosinophil patterns and their association with clinical outcomes. The goal of this study was to assess associations between longitudinal persistence of eosinophil elevations and both clinical outcomes and health care resource utilization (HCRU). Methods Data were extracted from 2 databases in the United Kingdom. Patients included were aged ≥13 years, had active asthma, and had ≥3 blood eosinophil count (BEC) recordings. Patients were categorized by BEC as: never high (all BEC ≤300 cells/µL), intermittently high (≥1 BEC >300 cells/µL but <75% of BEC >300 cells/µL), or persistently high (≥75% of BEC >300 cells/µL). Asthma exacerbations, asthma control (risk domain, overall, and full), and HCRU were evaluated for 12 months after the last BEC. Results The study population comprised 148,021 patients. Persistently high, intermittently high, and never high eosinophil patterns were detected in 13.6%, 40.5%, and 45.9% of patients, respectively. Patients with ≥1 elevated BEC were at greater risk for severe asthma exacerbations, regardless of whether the elevation was persistent (rate ratio [RR]: 1.28 [95% CI 1.24–1.33]; P < 0.001) or intermittent (RR: 1.24 [95% CI 1.21–1.27]; P < 0.001), compared with patients with no eosinophil elevations. Full asthma control was achieved by <25% of patients across eosinophil pattern groups, and HCRU did not appreciably differ, although patients with persistently high BEC had the shortest hospital stay duration among the groups. Conclusion These data suggest that elevated blood eosinophils, regardless of persistency, signify increased risk of severe asthma exacerbations.
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Affiliation(s)
- Trung N Tran
- Global Medicine Development, AstraZeneca, Gaithersburg, MD, USA
| | | | - Victoria Carter
- Observational and Pragmatic Research Institute, Singapore.,Optimum Patient Care, Cambridge, UK
| | - David B Price
- Observational and Pragmatic Research Institute, Singapore.,Optimum Patient Care, Cambridge, UK.,Division of Applied Health Sciences, Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
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Abstract
PURPOSE OF REVIEW Finding suitable biomarkers to phenotype asthma, identify individuals at risk of worsening and guide treatment is highly prioritized in asthma research. We aimed to provide an analysis of currently used and upcoming biomarkers, focusing on developments published in the past 2 years. RECENT FINDINGS Type 2 inflammation is the most studied asthma mechanism with the most biomarkers in the pipeline. Blood eosinophils and fractional exhaled nitric oxide (FeNO) are those most used clinically. Recent developments include their ability to identify individuals at higher risk of exacerbations, faster decline in lung function and more likely to benefit from anti-IL-5 and anti-IL-4/-13 treatment. Certain patterns of urinary eicosanoid excretion also relate to type 2 inflammation. Results of recent trials investigating the use of serum periostin or dipeptidyl peptidase-4 to guide anti-IL-13 therapy were somewhat disappointing. Less is known about non-type 2 inflammation but blood neutrophils and YKL-40 may be higher in patients with evidence of non-type 2 asthma. Volatile organic compounds show promise in their ability to distinguish both eosinophilic and neutrophilic asthma. SUMMARY The ultimate panel of biomarkers for identification of activated inflammatory pathways and treatment strategies in asthma patients still lies in the future, particularly for non-type 2 asthma, but potential candidates are available.
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Hedman AM, Kuja-Halkola R, Örtqvist AK, van Hage M, Almqvist C, Nordlund B. Genetic effects of allergen-specific IgE levels on exhaled nitric oxide in schoolchildren with asthma: The STOPPA twin study. Pediatr Allergy Immunol 2021; 32:709-719. [PMID: 33349970 PMCID: PMC8248142 DOI: 10.1111/pai.13438] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 12/08/2020] [Accepted: 12/16/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Exhaled nitric oxide and blood eosinophils are clinical asthma T-helper type 2 markers in use. Immunoglobulin E (IgE) is often involved in the inflammation associated with atopic asthma. The effect of both blood eosinophils and allergen-specific IgE on exhaled nitric oxide levels is not completely understood. Twin-design studies can improve understanding of the underlying contribution of genetically and/or environmentally driven inflammation markers in asthma. Our aim was to disentangle the covariance between asthma and exhaled nitric oxide into genetic and environmental contributions that can account for inflammation markers in a paediatric population. METHODS This population-based, cross-sectional twin study enrolled 612 monozygotic (MZ) and same-sex dizygotic (DZ) schoolchildren. Multivariate structural equation modelling was utilized to separate the covariance between asthma and exhaled nitric oxide into genetic and/or environmental effects, taking allergen-specific IgE level and blood eosinophil count into account while controlling for confounding factors. RESULTS The cross-twin/cross-trait correlations had a higher magnitude in the MZ twins than in the DZ twins, indicating that genes affect the association. The likelihood ratio test for model fitting resulted in the AE model (ie additive genetic effects, A, and non-shared environmental effects, E) as the most parsimonious. A majority, 73%, of the phenotypic correlation between asthma and exhaled nitric oxide, r = .19 (0.05-0.33), was attributable to genetic effects which mainly was due to the allergen-specific IgE level. CONCLUSIONS This study indicates that the association between asthma and exhaled nitric oxide in children is to a large extent explained by genetics via allergen-specific IgE level and not blood eosinophils. This might partly explain the clinical heterogeneity in this group. A next step could be to include allergen-specific IgE level in multivariate omic studies.
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Affiliation(s)
- Anna M Hedman
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Ralf Kuja-Halkola
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Anne K Örtqvist
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Obstetrics and Gynecology, Visby lasarett, Gotland, Sweden
| | - Marianne van Hage
- Division of Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Pediatric Allergy and Pulmonology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Björn Nordlund
- Pediatric Allergy and Pulmonology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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9
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The Predictive Role of Biomarkers and Genetics in Childhood Asthma Exacerbations. Int J Mol Sci 2021; 22:ijms22094651. [PMID: 33925009 PMCID: PMC8124320 DOI: 10.3390/ijms22094651] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 12/24/2022] Open
Abstract
Asthma exacerbations are associated with significant childhood morbidity and mortality. Recurrent asthma attacks contribute to progressive loss of lung function and can sometimes be fatal or near-fatal, even in mild asthma. Exacerbation prevention becomes a primary target in the management of all asthmatic patients. Our work reviews current advances on exacerbation predictive factors, focusing on the role of non-invasive biomarkers and genetics in order to identify subjects at higher risk of asthma attacks. Easy-to-perform tests are necessary in children; therefore, interest has increased on samples like exhaled breath condensate, urine and saliva. The variability of biomarker levels suggests the use of seriate measurements and composite markers. Genetic predisposition to childhood asthma onset has been largely investigated. Recent studies highlighted the influence of single nucleotide polymorphisms even on exacerbation susceptibility, through involvement of both intrinsic mechanisms and gene-environment interaction. The role of molecular and genetic aspects in exacerbation prediction supports an individual-shaped approach, in which follow-up planning and therapy optimization take into account not only the severity degree, but also the risk of recurrent exacerbations. Further efforts should be made to improve and validate the application of biomarkers and genomics in clinical settings.
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Mallah N, Rodriguez-Segade S, Gonzalez-Barcala FJ, Takkouche B. Blood eosinophil count as predictor of asthma exacerbation. A meta-analysis. Pediatr Allergy Immunol 2021; 32:465-478. [PMID: 33135257 DOI: 10.1111/pai.13403] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/26/2020] [Accepted: 10/28/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Evidence about the association of high blood eosinophil count with asthma exacerbation is inconsistent and unclear. The objective of this meta-analysis was to determine whether elevated blood eosinophil count predicts asthma exacerbation. METHODS We searched MEDLINE, EMBASE, and additional databases, without any language restriction. We also checked the reference lists of the included studies and of relevant systematic reviews. The main outcome was the occurrence of asthma exacerbation. We calculated global pooled odds ratios (ORs) and their 95% confidence intervals (CIs) and performed predefined subgroup analyses. We appraised the quality of the studies using Newcastle-Ottawa Scale, examined the heterogeneity between studies, assessed publication bias, and carried out sensitivity analyses. RESULTS Among 1567 retrieved publications, 23 observational studies comprising 155,772 participants met the inclusion criteria. High blood eosinophil count was associated with higher odds of asthma exacerbation [OR: 1.31 (95% CI: 1.16, 1.49)], specifically with asthma-related outpatient visits [OR: 1.46 (95% CI: 1.25, 1.70)] and emergency department visits [OR: 1.63 (95% CI: 1.29, 2.07)]. A significant association was observed starting from an eosinophils' cutoff value of 200 cells/μl. The association was observed for cohort studies [OR: 1.30 (95%CI: 1.13, 1.49)], North American studies [OR: 1.43 (95%CI: 1.31, 1.57)], Asian populations [OR: 1.67 (95%CI: 1.34, 2.08)], children [OR: 1.38 (95%CI: 1.22, 1.56)], and studies that adjusted for inhaled corticosteroids therapy [OR: 1.42 (95%CI: 1.28, 1.56)]. CONCLUSIONS Blood eosinophil counts ≥ 200 cells/µL are associated with asthma exacerbation. Blood eosinophil count is a modifiable factor that could be addressed in asthma management strategies.
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Affiliation(s)
- Narmeen Mallah
- Department of Preventive Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBER-ESP), Carlos III Health Research Institute, Madrid, Spain
| | - Santiago Rodriguez-Segade
- Department of Respiratory Medicine, University Hospital of Santiago de Compostela (CHUS), Santiago de Compostela, Spain
| | - Francisco-Javier Gonzalez-Barcala
- Department of Respiratory Medicine, University Hospital of Santiago de Compostela (CHUS), Santiago de Compostela, Spain.,Department of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain.,Spanish Biomedical Research Networking Centre (CIBER-ES), Carlos III Health Research Institute, Madrid, Spain.,Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Bahi Takkouche
- Department of Preventive Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBER-ESP), Carlos III Health Research Institute, Madrid, Spain.,Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
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11
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Donath H, Kluge S, Sideri G, Trischler J, Jerkic SP, Schulze J, Zielen S, Blumchen K. Hospitalization, Asthma Phenotypes, and Readmission Rates in Pre-school Asthma. Front Pediatr 2020; 8:562843. [PMID: 33330266 PMCID: PMC7716437 DOI: 10.3389/fped.2020.562843] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/13/2020] [Indexed: 01/19/2023] Open
Abstract
Objective: Children with pre-school asthma suffer disproportionally more often from severe asthma exacerbations with emergency visits and hospital admissions compared to school children. Despite this high disease burden, there are only a few reports looking at this particular severe asthma cohort. Similarly, there is little real-life research on the distribution of asthma phenotypes and personalized treatment at discharge in this age group. Patients and Methods: Retrospective analysis of the electronic charts of all children aged 1-5 years with asthma hospitalizations (ICD J45) at the Frankfurt University between 2008 and 2017. An acute severe asthma exacerbation was defined as dyspnea, oxygen demand, and/or systemic steroid therapy. Age, gender, duration of hospitalization, asthma phenotype, treatment, and readmission rate were analyzed. Results: Of 572 patients, 205 met the definition of acute severe asthma. The phenotypic characterization showed 56.1% had allergic asthma, 15.2% eosinophilic asthma and 28.7% non-allergic asthma. Of these patients, 71.7% were discharged with inhaled corticosteroids (ICS) or ICS + long-acting-beta-agonists (LABA), 15.1% with leukotriene antagonists (LTRA) and 7.3% salbutamol on demand. The rate of emergency presentations (emergency department and readmission) within 12 months after discharge was high (n = 42; 20.5%). No phenotype tailored treatment was detectable. Neither the number of eosinophils (>300/μl) nor the treatment at discharge had an effect on emergency visits and readmission rate. Conclusion: Despite protective therapy with ICS, ICS + LABA, or LTRA, the readmission rate was high. Thus, current care and treatment strategies should be reevaluated continuously, in order to better control asthma in pre-school children and prevent hospitalization.
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Affiliation(s)
| | | | | | | | | | | | - Stefan Zielen
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
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12
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Hegewald MJ, Horne BD, Trudo F, Kreindler JL, Chung Y, Rea S, Blagev DP. Blood Eosinophil Count and Hospital Readmission in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2020; 15:2629-2641. [PMID: 33122901 PMCID: PMC7591040 DOI: 10.2147/copd.s251115] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/07/2020] [Indexed: 01/08/2023] Open
Abstract
Purpose This retrospective, observational cohort study investigated the association of blood eosinophil counts within 1 week of hospitalization for acute exacerbation of COPD (AECOPD) with subsequent risk of all-cause and COPD-related readmission from a large integrated health system. Patients and Methods Electronic medical records were extracted for index hospitalization for AECOPD at all Intermountain Healthcare hospitals. The primary outcome was the relationship of blood eosinophil count to 30-day all-cause readmission; secondary outcomes were 60-day, 90-day, and 12-month all-cause readmission, COPD-related readmission, and empiric derivation of the eosinophil count with the highest area under the curve (AUC) for predicting 30-day all-cause readmission. Results Of 2445 included patients, 1935 (79%) had a blood eosinophil count <300 cells/µL and 510 (21%) had a count ≥300 cells/µL. Using a 300-cells/μL threshold, there was no significant difference between high and low eosinophil groups in 30-day (odds ratio [OR]=1.05, 95% confidence interval [CI]=0.75–1.47) or 60-day (OR=1.15, 95% CI=0.88–1.51) all-cause readmissions. However, patients with greater (versus lesser) eosinophil counts had increased 90-day and 12-month all-cause readmissions (OR=1.35, 95% CI=1.06–1.72, and OR=1.32, 95% CI=1.07–1.62). COPD-related readmission rates were significantly greater for patients with greater (versus lesser) eosinophil counts at 30, 60, and 90 days and 12 months (OR range=1.52–1.97). A total of 70 cells/µL had the most discriminatory power to predict 30-day all-cause readmission (highest AUC). Conclusion Eosinophil counts in patients with COPD were not associated with a difference in 30-day all-cause readmissions. However, greater eosinophil counts were associated with increased risk of all-cause readmission at 90 days and 12 months and COPD-related readmission at 30, 60, and 90 days and 12 months. Patients with eosinophils <70 cells/μL had the lowest risk for 30-day all-cause readmission. Blood eosinophils in patients hospitalized with AECOPD may be a useful biomarker for the risk of hospital readmission.
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Affiliation(s)
- Matthew J Hegewald
- Pulmonary and Critical Care Medicine Division, Intermountain Medical Center, Murray, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
| | - Benjamin D Horne
- Intermountain Heart Institute at Intermountain Healthcare, Salt Lake City, UT, USA.,Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Frank Trudo
- Health Economics Outcomes Research, AstraZeneca, Wilmington, DE, USA
| | - James L Kreindler
- Health Economics Outcomes Research, AstraZeneca, Wilmington, DE, USA
| | - Yen Chung
- Health Economics Outcomes Research, AstraZeneca, Wilmington, DE, USA
| | - Susan Rea
- Enterprise Analytics, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Denitza P Blagev
- Pulmonary and Critical Care Medicine Division, Intermountain Medical Center, Murray, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
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13
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Graff S, Vanwynsberghe S, Brusselle G, Hanon S, Sohy C, Dupont LJ, Peche R, Michils A, Pilette C, Joos G, Louis RE, Schleich FN. Chronic oral corticosteroids use and persistent eosinophilia in severe asthmatics from the Belgian severe asthma registry. Respir Res 2020; 21:214. [PMID: 32787967 PMCID: PMC7424982 DOI: 10.1186/s12931-020-01460-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/17/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Severe asthma (SA) may require frequent courses or chronic use of oral corticosteroids (OCS), inducing many known side effects and complications. Therefore, it is important to identify risk factors of chronic use of OCS in SA, considering the heterogeneity of clinical and inflammatory asthma phenotypes. Another aim of the present analysis is to characterize a subpopulation of severe asthmatics, in whom blood eosinophil counts (BEC) remain elevated despite chronic OCS treatment. METHODS In a cross-sectional analysis of 982 SA patients enrolled in the Belgian Severe Asthma Registry (BSAR) between March 2009 and February 2019, we investigated the characteristics of the OCS treated patients with special attention to their inflammatory profile. RESULTS At enrollment, 211 (21%) SA patients were taking maintenance OCS (median dose: 8 [IQR: 5-10]) mg prednisone equivalent). BEC was high (> 400/mm3) in 44% of the OCS treated population. Multivariable logistic regression analysis showed that risk factors for chronic use of OCS in SA were late-onset asthma (i.e. age of onset > 40 yr), frequent exacerbations (i.e. ≥2 exacerbations in the previous year) and non-atopic asthma. Late-onset asthma was also a predictor for persistently high BEC in OCS treated SA patients. CONCLUSION These data showed a significant association between a persistently high BEC and late-onset asthma in OCS treated SA patients. Whether it is poor compliance to treatment or corticosteroid insensitivity the reasons for this association warrants further investigation.
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Affiliation(s)
- S Graff
- Department of Respiratory Medicine, CHU Sart-Tilman, I3GIGA Research Group, University of Liege, Liege, Belgium.
| | - S Vanwynsberghe
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - G Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - S Hanon
- Respiratory Division, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - C Sohy
- Department of Respiratory Medicine, Centre Hospitalier Universitaire UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - L J Dupont
- Department of Respiratory Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - R Peche
- Department of Respiratory Medicine, CHU-Charleroi, A. Vésale Hospital, Charleroi, Belgium
| | - A Michils
- Chest Department, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - C Pilette
- Cliniques Universitaires St-Luc and Institute of Experimental and Clinical Research, Université Catholique de Louvain, Brussels, Belgium
| | - G Joos
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - R E Louis
- Department of Respiratory Medicine, CHU Sart-Tilman, I3GIGA Research Group, University of Liege, Liege, Belgium
| | - F N Schleich
- Department of Respiratory Medicine, CHU Sart-Tilman, I3GIGA Research Group, University of Liege, Liege, Belgium
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14
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Hussain Z, Shah SA, Mukherjee M, Sheikh A. Predicting the risk of asthma attacks in children, adolescents and adults: protocol for a machine learning algorithm derived from a primary care-based retrospective cohort. BMJ Open 2020; 10:e036099. [PMID: 32709646 PMCID: PMC7380838 DOI: 10.1136/bmjopen-2019-036099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Most asthma attacks and subsequent deaths are potentially preventable. We aim to develop a prognostic tool for identifying patients at high risk of asthma attacks in primary care by leveraging advances in machine learning. METHODS AND ANALYSIS Current prognostic tools use logistic regression to develop a risk scoring model for asthma attacks. We propose to build on this by systematically applying various well-known machine learning techniques to a large longitudinal deidentified primary care database, the Optimum Patient Care Research Database, and comparatively evaluate their performance with the existing logistic regression model and against each other. Machine learning algorithms vary in their predictive abilities based on the dataset and the approach to analysis employed. We will undertake feature selection, classification (both one-class and two-class classifiers) and performance evaluation. Patients who have had actively treated clinician-diagnosed asthma, aged 8-80 years and with 3 years of continuous data, from 2016 to 2018, will be selected. Risk factors will be obtained from the first year, while the next 2 years will form the outcome period, in which the primary endpoint will be the occurrence of an asthma attack. ETHICS AND DISSEMINATION We have obtained approval from OPCRD's Anonymous Data Ethics Protocols and Transparency (ADEPT) Committee. We will seek ethics approval from The University of Edinburgh's Research Ethics Group (UREG). We aim to present our findings at scientific conferences and in peer-reviewed journals.
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Affiliation(s)
- Zain Hussain
- Usher Institute, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Syed Ahmar Shah
- Usher Institute, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
- Asthma UK Centre for Applied Research (AUKCAR), The University of Edinburgh, Edinburgh, UK
| | - Mome Mukherjee
- Usher Institute, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
- Asthma UK Centre for Applied Research (AUKCAR), The University of Edinburgh, Edinburgh, UK
| | - Aziz Sheikh
- Usher Institute, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
- Asthma UK Centre for Applied Research (AUKCAR), The University of Edinburgh, Edinburgh, UK
- Division of Community Health Sciences, The University of Edinburgh, Edinburgh, UK
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15
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Biomarkers of Oxidative Stress and Inflammation in Chronic Airway Diseases. Int J Mol Sci 2020; 21:ijms21124339. [PMID: 32570774 PMCID: PMC7353047 DOI: 10.3390/ijms21124339] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/12/2020] [Accepted: 06/16/2020] [Indexed: 02/06/2023] Open
Abstract
Introduction: The global burden of chronic airway diseases represents an important public health concern. The role of oxidative stress and inflammation in the pathogenesis of these diseases is well known. The aim of this study is to evaluate the behavior of both inflammatory and oxidative stress biomarkers in patients with chronic bronchitis, current asthma and past asthma in the frame of a population-based study. Methods: For this purpose, data collected from the Gene Environment Interactions in Respiratory Diseases (GEIRD) Study, an Italian multicentre, multicase-control study, was evaluated. Cases and controls were identified through a two-stage screening process of individuals aged 20-65 years from the general population. Out of 16,569 subjects selected from the general population in the first stage of the survey, 2259 participated in the clinical evaluation. Oxidative stress biomarkers such as 8-oxo-7,8-dihydro-2′-deoxyguanosine (8-oxodG), 8-isoprostane and glutathione and inflammatory biomarkers such as Fractional Exhaled Nitric Oxide (FENO) and white blood cells were evaluated in 1878 subjects. Results: Current asthmatics presented higher levels of FENO (23.05 ppm), leucocytes (6770 n/µL), basophils (30.75 n/µL) and eosinophils (177.80 n/µL), while subjects with chronic bronchitis showed higher levels of GSH (0.29 mg/mL) and lymphocytes (2101.6 n/µL). The multivariable multinomial logistic regression confirmed high levels of leucocytes (RRR = 1.33), basophils (RRR = 1.48), eosinophils (RRR = 2.39), lymphocytes (RRR = 1.26) and FENO (RRR = 1.42) in subjects with current asthma. Subjects with past asthma had a statistically significant higher level of eosinophils (RRR = 1.78) with respect to controls. Subjects with chronic bronchitis were characterized by increased levels of eosinophils (RRR = 2.15), lymphocytes (RRR = 1.58), GSH (RRR = 2.23) and 8-isoprostane (RRR = 1.23). Conclusion: In our study, current asthmatics show a greater expression of the inflammatory profile compared to subjects who have had asthma in the past and chronic bronchitis. On the other hand, chronic bronchitis subjects showed a higher rate of expression of oxidative stress biomarkers compared to asthmatic subjects. In particular, inflammatory markers such as circulating inflammatory cells and FENO seem to be more specific for current asthma, while oxidative stress biomarkers such as glutathione and 8-isoprostane appear to be more specific and applicable to patients with chronic bronchitis.
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16
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Lebold KM, Jacoby DB, Drake MG. Inflammatory mechanisms linking maternal and childhood asthma. J Leukoc Biol 2020; 108:113-121. [PMID: 32040236 DOI: 10.1002/jlb.3mr1219-338r] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 12/26/2022] Open
Abstract
Asthma is a chronic inflammatory airway disease characterized by airway hyperresponsiveness, inflammation, and remodeling. Asthma often develops during childhood and causes lifelong decrements in lung function and quality of life. Risk factors for childhood asthma are numerous and include genetic, epigenetic, developmental, and environmental factors. Uncontrolled maternal asthma during pregnancy exposes the developing fetus to inflammatory insults, which further increase the risk of childhood asthma independent of genetic predisposition. This review focuses on the role of maternal asthma in the development of asthma in offspring. We will present maternal asthma as a targetable and modifiable risk factor for childhood asthma and discuss the mechanisms by which maternal inflammation increases childhood asthma risk. Topics include how exposure to maternal asthma in utero shapes structural lung development with a special emphasis on airway nerves, how maternal type-2 cytokines such as IL-5 activate the fetal immune system, and how changes in lung and immune cell development inform responses to aero-allergens later in life. Finally, we highlight emerging evidence that maternal asthma establishes a unique "asthma signature" in the airways of children, leading to novel mechanisms of airway hyperreactivity and inflammatory cell responses.
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Affiliation(s)
- Katie M Lebold
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - David B Jacoby
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Matthew G Drake
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
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17
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Coşkun O, Ercan N, Bostanci I. The peripheral blood inflammatory patterns in the control levels of asthma in children. J Asthma 2019; 58:299-306. [PMID: 31775526 DOI: 10.1080/02770903.2019.1698602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Asthma is the most common chronic inflammatory disease of childhood, but there are no useful and easily accessible laboratory tests routinely used in the diagnosis and follow-up of this disease in children. Therefore, this study aimed to investigate the roles of white blood cell (WBC) count, platelet count, mean platelet volume (MPV), and eosinophil percentage as full blood count inflammatory markers in evaluating the control level and follow-up of asthma in the pediatric age group. METHODS A retrospective review of patient records and files of 3,580 patients diagnosed with asthma at the University of Health Sciences in Ankara, Turkey was performed. Patients who met inclusion/exclusion criteria were divided into two groups based on the asthma control level: controlled and uncontrolled. Laboratory data were compared according to the asthma control levels, drug use status, and atopy status of the patients. RESULTS A total of 348 patients between 4 and 18 years of age, who were followed-up with the diagnosis of asthma, were included in this study. A significant difference was found between the controlled and uncontrolled groups of asthma patients in terms of the eosinophil percentage (mean ± SD, respectively; 3.493 ± 2.24; 4.992 ± 3.43; p = .003). When patients were grouped according to their asthma control levels and atopy status, only the eosinophil percentages were different in the logistic regression analysis (odds ratio = 1.276, 95% confidence interval = 1.113-1.462). CONCLUSION Our study showed that the percentage of eosinophils can be used as an asthma control parameter, but additional prospective studies would be desirable to confirm our results.
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Affiliation(s)
- Orhan Coşkun
- Department of Child Health and Diseases, Health Sciences University, Dr. Sami Ulus Maternity and Children Research and Training Hospital, Ankara, Turkey
| | - Nazli Ercan
- Department of Child Health and Diseases, Pediatric Immunology and Allergy, Health Sciences University, Gülhane Education and Research Hospital, Ankara, Turkey
| | - Ilknur Bostanci
- Department of Pediatric Immunology and Allergy, Health Sciences University, Dr. Sami Ulus Maternity and Children Research and Training Hospital, Ankara, Turkey
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18
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Martin RJ, Bel EH, Pavord ID, Price D, Reddel HK. Defining severe obstructive lung disease in the biologic era: an endotype-based approach. Eur Respir J 2019; 54:13993003.00108-2019. [PMID: 31515397 PMCID: PMC6917363 DOI: 10.1183/13993003.00108-2019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 08/19/2019] [Indexed: 11/05/2022]
Abstract
Severe obstructive lung disease, which encompasses asthma, chronic obstructive pulmonary disease (COPD) or features of both, remains a considerable global health problem and burden on healthcare resources. However, the clinical definitions of severe asthma and COPD do not reflect the heterogeneity within these diagnoses or the potential for overlap between them, which may lead to inappropriate treatment decisions. Furthermore, most studies exclude patients with diagnoses of both asthma and COPD. Clinical definitions can influence clinical trial design and are both influenced by, and influence, regulatory indications and treatment recommendations. Therefore, to ensure its relevance in the era of targeted biologic therapies, the definition of severe obstructive lung disease must be updated so that it includes all patients who could benefit from novel treatments and for whom associated costs are justified. Here, we review evolving clinical definitions of severe obstructive lung disease and evaluate how these have influenced trial design by summarising eligibility criteria and primary outcomes of phase III randomised controlled trials of biologic therapies. Based on our findings, we discuss the advantages of a phenotype- and endotype-based approach to select appropriate populations for future trials that may influence regulatory approvals and clinical practice, allowing targeted biologic therapies to benefit a greater proportion and range of patients. This calls for co-ordinated efforts between investigators, pharmaceutical developers and regulators to ensure biologic therapies reach their full potential in the management of severe obstructive lung disease.
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Affiliation(s)
- Richard J Martin
- National Jewish Health and the University of Colorado, Denver, CO, USA
| | - Elisabeth H Bel
- Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Ian D Pavord
- Respiratory Medicine Unit and NIHR Oxford Respiratory BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - David Price
- Observational and Pragmatic Research Institute, Singapore.,Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
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19
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Håkansson KEJ, Rasmussen LJH, Godtfredsen NS, Tupper OD, Eugen-Olsen J, Kallemose T, Andersen O, Ulrik CS. The biomarkers suPAR and blood eosinophils are associated with hospital readmissions and mortality in asthma - a retrospective cohort study. Respir Res 2019; 20:258. [PMID: 31730462 PMCID: PMC6858677 DOI: 10.1186/s12931-019-1234-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/07/2019] [Indexed: 01/21/2023] Open
Abstract
Introduction Prognostic biomarkers in asthma are needed. The biomarker soluble urokinase plasminogen activator receptor (suPAR) has been associated with asthma control and with prognosis in acutely admitted medical patients. We investigated if suPAR and blood eosinophil counts at the time of admission for asthma are associated with readmission and mortality. Methods Our cohort comprised 1341 patients (median age 45.3, IQR 30.1–63.1) acutely admitted with a diagnosis of asthma to Hvidovre Hospital, Denmark (November 2013 to March 2017). Patients had suPAR and blood eosinophils measured at admission. Outcomes were 365-day readmission and all-cause mortality. Logistic regression analysis adjusted for age, sex, C-reactive protein, and Charlson comorbidity score was used to assess the association of the two biomarkers with readmission and all-cause mortality. Results Compared to event-free patients, patients who were either readmitted (n = 452, 42.3%) or died (n = 57, 5.3%) had significantly higher suPAR concentrations (p < 0.0001) and lower eosinophil counts (p = 0.0031) at admission. The highest odds of readmission or mortality were observed for patients in either the 4th suPAR quartile (p < 0.0001) or with eosinophil counts < 150 cells/μL at admission. Increasing levels of suPAR were associated with 365-day readmission (OR 1.3 [1.0–1.6]; p = 0.05) and mortality (OR 2.9 [1.7–5.1]; p = 0.0002). Eosinophil count > 300 cells/μL was significantly associated with lower odds of readmission (OR 0.64 [0.5–0.9]; p = 0.005) and lower mortality (OR 0.7 [0.6–0.9]; p = 0.0007). Conclusions In patients acutely admitted with asthma, elevated suPAR concentrations together with blood eosinophil count < 150 cells/μL at the time of hospital admission were associated with both 365-day all-cause readmission and mortality.
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Affiliation(s)
- K E J Håkansson
- Department of Respiratory Medicine, Copenhagen University Hospital Amager and Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark.
| | - Line J H Rasmussen
- Clinical Research Centre, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark.,Department of Psychology and Neuroscience, Duke University, Durham, NC, USA
| | - Nina S Godtfredsen
- Department of Respiratory Medicine, Copenhagen University Hospital Amager and Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Oliver D Tupper
- Department of Respiratory Medicine, Copenhagen University Hospital Amager and Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
| | - Jesper Eugen-Olsen
- Clinical Research Centre, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Thomas Kallemose
- Clinical Research Centre, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Ove Andersen
- Clinical Research Centre, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Emergency Department, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Copenhagen University Hospital Amager and Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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20
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Price DB, Bosnic-Anticevich S, Pavord ID, Roche N, Halpin DMG, Bjermer L, Usmani OS, Brusselle G, Ming SWY, Rastogi S. Association of elevated fractional exhaled nitric oxide concentration and blood eosinophil count with severe asthma exacerbations. Clin Transl Allergy 2019; 9:41. [PMID: 31452870 PMCID: PMC6702739 DOI: 10.1186/s13601-019-0282-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/08/2019] [Indexed: 12/13/2022] Open
Abstract
Background Blood eosinophil count (BEC) and fractional exhaled nitric oxide (FeNO) concentration are established biomarkers in asthma, associated particularly with the risk of exacerbations. We evaluated the relationship of BEC and FeNO as complementary and independent biomarkers of severe asthma exacerbations. Methods This observational study included data from the Optimum Patient Care Research Database. Asthma patients (18–80 years) with valid continuous data for 1 year before FeNO reading, ≥ 1 inhaled corticosteroid prescription, and BEC recorded ≤ 5 years before FeNO reading were separated into cohorts. Categorisation 1 was based on the American Thoracic Society criteria for elevated FeNO concentration (high: ≥ 50 ppb; non-high: < 25 ppb) and BEC (high: ≥ 0.300 × 109 cells/L; non-high: < 0.300 × 109 cells/L). Categorisation 2 (FeNO concentration, high: ≥ 35 ppb; non-high: < 35 ppb) was based on prior research. Reference groups included patients with neither biomarker raised. Results In categorisation 1, patients with either high FeNO or high BEC (n = 200) had a numerically greater exacerbation rate (unadjusted rate ratio, 1.31 [95% confidence interval: 0.97, 1.76]) compared with patients in the reference group. Combination of high FeNO and high BEC (n = 27) resulted in a significantly greater exacerbation rate (3.67 [1.49, 9.04]). Similarly, for categorisation 2, when both biomarkers were raised (n = 53), a significantly greater exacerbation rate was observed (1.72 [1.00, 2.93]). Conclusion The combination of high FeNO and high BEC was associated with significantly increased severe exacerbation rates in the year preceding FeNO reading, suggesting that combining FeNO and BEC measurements in primary care may identify asthma patients at risk of exacerbations. Electronic supplementary material The online version of this article (10.1186/s13601-019-0282-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David B Price
- 1Observational and Pragmatic Research Institute, Singapore, Singapore.,2Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | | | - Ian D Pavord
- 4Oxford NIHR Respiratory Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | | | | | | | | | - Sarang Rastogi
- 10Global Medical Affairs, AstraZeneca, Gaithersburg, USA
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Wijnant SRA, Lahousse L, De Buyzere ML, Brusselle GG, Rietzschel ER. Prevalence of Asthma and COPD and Blood Eosinophil Count in a Middle-Aged Belgian Population. J Clin Med 2019; 8:jcm8081122. [PMID: 31357728 PMCID: PMC6723474 DOI: 10.3390/jcm8081122] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/20/2019] [Accepted: 07/25/2019] [Indexed: 02/02/2023] Open
Abstract
Various phenotypes exist in asthma and Chronic Obstructive Pulmonary Disease (COPD). These are important to identify in order to guide treatment decisions. We aim to investigate the prevalence and clinical characteristics of obstructive airway diseases in the middle-aged population. We estimated the prevalence of COPD and/or asthma in the Asklepios cohort study (Belgium), using information from the third European Community Respiratory Health Survey (ECRHS3), medical records, and spirometry. Respiratory symptoms, respiratory medication, and current disease status distinguished clinical from sub-clinical cases. In addition, we compared the blood eosinophil count/µL (median [IQR]) between cases and controls. Of the 2221 participants (mean age 56.1 ± 5.9 years; 48.7% males), 138 (6.2%) participants had clinical current asthma, 22 (1.0%) participants had sub-clinical ever asthma, 102 (4.6%) had sub-clinical spirometry-defined COPD, 104 (4.6%) participants had clinical spirometry-confirmed COPD, and 11 (0.5%) had asthma and COPD overlap (ACO). Clinical current asthma (160.0 [110.0–250.0]), sub-clinical ever asthma (170.0 [110.0–230.0]), and clinical COPD (160.0 [110.0–220.0])—but less sub-clinical COPD (140.0 [90.0–210.0])—had higher eosinophil counts, compared to controls (130.0 [80.0–200.0]). We conclude that obstructive airway diseases are prevalent in the middle-aged Asklepios cohort. Moreover, the systemic eosinophil count is increased in clinical COPD cases, and in asthma cases regardless of clinical remission.
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Affiliation(s)
- Sara R A Wijnant
- Department of Respiratory Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium
- Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Marc L De Buyzere
- Department of Cardiology, Ghent University Hospital, and Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Guy G Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, and Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Ernst R Rietzschel
- Department of Cardiology and Biobanking and Cardiovascular Epidemiology, Ghent University Hospital and Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium.
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Shah SP, Grunwell J, Shih J, Stephenson S, Fitzpatrick AM. Exploring the Utility of Noninvasive Type 2 Inflammatory Markers for Prediction of Severe Asthma Exacerbations in Children and Adolescents. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2624-2633.e2. [PMID: 31100552 DOI: 10.1016/j.jaip.2019.04.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Noninvasive markers of type 2 inflammation are needed to identify children and adolescents who might benefit from personalized biologic therapy. OBJECTIVE We hypothesized that blood eosinophil counts would predict 1 or more acute visits for asthma and that prediction could be improved with the addition of a second, noninvasive type 2 inflammatory biomarker. METHODS Children and adolescents 5 to 21 years (N = 589) with an asthma exacerbation necessitating systemic corticosteroid treatment in the previous year completed a characterization visit and telephone calls at 6 and 12 months. The primary outcome was an acute visit for asthma with receipt of systemic corticosteroids. Acute visits were verified by medical record review. Exploratory outcomes included time to first acute visit and hospitalization. RESULTS Acute visits occurred in 106 (35.5%) children and 72 (24.8%) adolescents. Elevated blood eosinophils were associated with increased odds and shorter time to first acute visit, but optimal cut-points differed by age (≥150 vs ≥300 cells/μL for children vs adolescents, respectively). The addition of a second marker of type 2 inflammation did not improve prediction in children, but increased the odds and hazard of an acute visit up to 16.2% and 11.9%, respectively, in adolescents. Similar trends were noted for hospitalizations. CONCLUSIONS Blood eosinophils and other noninvasive markers of type 2 inflammation may be useful in the clinical assessment of children and adolescents with asthma. However, features of type 2 inflammation vary by age. Whether children and adolescents also respond differently to management of type 2 inflammation is unclear and warrants further evaluation.
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Affiliation(s)
- Samar P Shah
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jocelyn Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jennifer Shih
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga.
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Metabolic Syndrome Biomarkers of World Trade Center Airway Hyperreactivity: A 16-Year Prospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16091486. [PMID: 31035527 PMCID: PMC6539892 DOI: 10.3390/ijerph16091486] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/16/2019] [Accepted: 04/18/2019] [Indexed: 12/28/2022]
Abstract
Airway hyperreactivity (AHR) related to environmental exposure is a significant public health risk worldwide. Similarly, metabolic syndrome (MetSyn), a risk factor for obstructive airway disease (OAD) and systemic inflammation, is a significant contributor to global adverse health. This prospective cohort study followed N = 7486 World Trade Center (WTC)-exposed male firefighters from 11 September 2001 (9/11) until 1 August 2017 and investigated N = 539 with newly developed AHR for clinical biomarkers of MetSyn and compared them to the non-AHR group. Male firefighters with normal lung function and no AHR pre-9/11 who had blood drawn from 9 September 2001–24 July 2002 were assessed. World Trade Center-Airway Hyperreactivity (WTC-AHR) was defined as either a positive bronchodilator response (BDR) or methacholine challenge test (MCT). The electronic medical record (EMR) was queried for their MetSyn characteristics (lipid profile, body mass index (BMI), glucose), and routine clinical biomarkers (such as complete blood counts). We modeled the association of MetSyn characteristics at the first post-9/11 exam with AHR. Those with AHR were significantly more likely to be older, have higher BMIs, have high intensity exposure, and have MetSyn. Smoking history was not associated with WTC-AHR. Those present on the morning of 9/11 had 224% increased risk of developing AHR, and those who arrived in the afternoon of 9/11 had a 75.9% increased risk. Having ≥3 MetSyn parameters increased the risk of WTC-AHR by 65.4%. Co-existing MetSyn and high WTC exposure are predictive of future AHR and suggest that systemic inflammation may be a contributor.
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Kaplan A, Hardjojo A, Yu S, Price D. Asthma Across Age: Insights From Primary Care. Front Pediatr 2019; 7:162. [PMID: 31131265 PMCID: PMC6510260 DOI: 10.3389/fped.2019.00162] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 04/08/2019] [Indexed: 11/16/2022] Open
Abstract
Asthma is a heterogeneous disease comprising of multiple phenotypes and affects patients from childhood up to old age. In this review, we summarize the current knowledge on the similarities and differences in asthma across different age-groups, with emphasis on the perspective from primary care. Despite the similar disease presentation, phenotyping studies showed that there are differences in the distribution of phenotypes of asthma presenting in childhood compared to that in adulthood. Whereas, asthma with early age of onset tends to be of the atopic phenotype, the disease shifts toward the non-atopic phenotypes at later ages. Studies within primary care patients aiming to elucidate risk factors for future asthma exacerbation have shown pediatric and elderly patients to be at higher risk for future asthma attacks compared to other adult patients. Regardless, both pediatric and adult studies demonstrated previous asthma episodes and severity, along with high blood eosinophil to predict subsequent asthma attacks. Differences in childhood and adult asthma are not limited to the underlying phenotypes but also extends to the challenges in the diagnosis, treatment, and management of the disease. Diagnosis of asthma is complicated by age-specific differential diagnoses such as infectious wheezing and nasal obstruction in children, and aging-related problems such as heart disease and obesity in the elderly. There are also age-related issues leading to decreased disease control such as non-adherence, tobacco use, difficulty in using inhalers and corticosteroid-related side effects which hinder asthma control at different patient age-groups. Several clinical guidelines are available to guide the diagnosis and drug prescription of asthma in pediatric patients. However, there are conflicting recommendations for the diagnostic tools and treatment for pediatric patients, posing additional challenges for primary care physicians in working with multiple guidelines. While tools such as spirometry and peak flow variability are often available in primary care, their usage in preschool patients is not consistently recommended. FeNO measurement may be a valuable non-invasive tool which can be adopted by primary physicians to assist asthma diagnosis in preschool-age patients.
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Affiliation(s)
- Alan Kaplan
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Antony Hardjojo
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Shaylynn Yu
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore.,Division of Applied Health Sciences, Centre of Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom.,Optimum Patient Care, Cambridge, United Kingdom
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