Adherence to Prescribed E-Diary Recording by Patients With Seasonal Allergic Rhinitis: Observational Study

Patient adherence and response time in electronic patient-reported outcomes: insights from three longitudinal clinical trials

PURPOSE

Patient-reported outcome measures (PROMs) are used to collect data on disease symptoms in support of clinical trial endpoints. Clinical studies can last a year or more, and the patients' adherence and response time to daily at-home questionnaires may vary significantly over time. The aim of this study was to understand patterns and changes in patients' completion of daily PROMs during longitudinal clinical studies.

METHODS

Data were collected from 1342 patients randomized into three respiratory clinical trials (NCT03401229, NCT03347279, and NCT03406078). PROMs were completed by patients using electronic handheld devices that collected the starting and completion times. A Bayesian generalized linear mixed-effects model was used to identify unbiased coefficients associated with PROM adherence and response time using patient, site, and calendar features as covariates.

RESULTS

Adherence decreased over time after randomization, and the rate of decrease was higher in younger patients. The 14-day pre-randomization adherence was correlated with adherence throughout the study. Patients were also more adherent during working days compared to non-working days. Oldest patients took twice as long to complete PROMs throughout the study; however, the response time for all patients decreased during the first month of the study regardless of age. Response time increased 7 days before and after the date of a scheduled clinic visit and when a patient-reported higher symptom burden.

CONCLUSION

Detailed analyses of adherence and response time for daily PROMs in clinical trials can provide significant insights about trends of patient behavior in longitudinal clinical studies with high baseline adherence.

Digitally-enabled, person-centred care (PCC) in allergen immunotherapy: An ARIA-EAACI Position Paper

In rhinitis and asthma, several mHealth apps have been developed but only a few have been validated. However, these apps have a high potential for improving person-centred care (PCC), especially in allergen immunotherapy (AIT). They can provide support in AIT initiation by selecting the appropriate patient and allergen shared decision-making. They can also help in (i) the evaluation of (early) efficacy, (ii) early and late stopping rules and (iii) the evaluation of (carried-over) efficacy after cessation of the treatment course. Future perspectives have been formulated in the first report of a joint task force (TF)-Allergic Rhinitis and Its Impact on Asthma (ARIA) and the European Academy of Allergy and Clinical Immunology (EAACI)-on digital biomarkers. The TF on AIT now aims to (i) outline the potential of the clinical applications of mHealth solutions, (ii) express their current limitations, (iii) make proposals regarding further developments for both clinical practice and scientific purpose and (iv) suggest which of the tools might best comply with the purpose of digitally-enabled PCC in AIT.

Hot topics in allergen immunotherapy, 2023: Current status and future perspective

The importance of allergen immunotherapy (AIT) is multifaceted, encompassing both clinical and quality-of-life improvements and cost-effectiveness in the long term. Key mechanisms of allergen tolerance induced by AIT include changes in memory type allergen-specific T- and B-cell responses towards a regulatory phenotype with decreased Type 2 responses, suppression of allergen-specific IgE and increased IgG1 and IgG4, decreased mast cell and eosinophil numbers in allergic tissues and increased activation thresholds. The potential of novel patient enrolment strategies for AIT is taking into account recent advances in biomarkers discoveries, molecular allergy diagnostics and mobile health applications contributing to a personalized approach enhancement that can increase AIT efficacy and compliance. Artificial intelligence can help manage and interpret complex and heterogeneous data, including big data from omics and non-omics research, potentially predict disease subtypes, identify biomarkers and monitor patient responses to AIT. Novel AIT preparations, such as synthetic compounds, innovative carrier systems and adjuvants, are also of great promise. Advances in clinical trial models, including adaptive, complex and hybrid designs as well as real-world evidence, allow more flexibility and cost reduction. The analyses of AIT cost-effectiveness show a clear long-term advantage compared to pharmacotherapy. Important research questions, such as defining clinical endpoints, biomarkers of patient selection and efficacy, mechanisms and the modulation of the placebo effect and alternatives to conventional field trials, including allergen exposure chamber studies are still to be elucidated. This review demonstrates that AIT is still in its growth phase and shows immense development prospects.

Conception and pilot testing of a self-management health application for patients with pollen-related allergic rhinitis and allergic asthma-the APOLLO app

It has been shown that pollen information services are an important self-management tool for patients with pollen-related allergic rhinitis (AR) and allergic asthma (AA). This study aimed to design an online application for patients with AR and AA, which supports patients to better manage their disease as well as to evaluate the app and present the first results of the pilot study. The pollen data were obtained from the electronic pollen information network of Bavaria, Germany. Participants were asked to fill in their allergy-related complaints in the app over a 60-day period. Subsequently, the app was evaluated. Indices and diagrams visualized the participants' individual complaints as well as the daily pollen concentration in the air. In order to motivate participants to complete the app on a daily basis, we used elements of gamification. Two thirds of the participants (N = 46) reported feeling better informed about pollen counts and their allergy when using the app. The app's simple and comprehensible design was rated positively. More than 80% of the participants would recommend the app to their family and friends. The app can be a tool for patients with AR and AA to better understand their disease.

The "allergic nose as a pollen detector" concept: e-Diaries to predict pollen trends

Hirst pollen traps and operator pollen recognition are worldwide used by aerobiologists, providing essential services for the diagnosis and monitoring of allergic patients. More recently, semiautomated or fully automated detector systems have been developed, which facilitate prediction of pollen exposure and risk for the individual patient. In parallel, smartphone apps consisting of short questionnaires filled in daily by the patient/user provide daily scores, time trajectories, and descriptive reports of the severity of respiratory allergies in patients with pollen allergy. The usual scientific and clinical approach to this matter is to monitor the environment (pollen concentration) in order to predict the risk of symptoms (allergic rhinitis) in a population. We discuss here the opposite, contraintuitive possibility, that is, the use of e-diaries to collect daily information of mono-sensitized pollen-allergic patients in order to predict the clinically efficient airborne exposure to a given pollen, area, and time period. In line with the "Patient as Sensor" concept, proposed in 2013 by Bernd Resch, the "allergic nose" may be used as a pollen detector in addition to existing calibrated hardware sensors, namely the pollen stations, thus contributing with individual measurements, sensations, and symptoms' perception. The target of this review is to present a novel concept of pollen monitoring based on "pollen-detector" patients to inspire future cooperative studies aimed at investigating and hopefully validating our hypothesis.

Factors predicting the outcome of allergen-specific nasal provocation test in children with grass pollen allergic rhinitis

Background

Nasal provocation testing (NPT) is a reference methodology to identify the culprit allergen in patients with allergic rhinitis. Selecting the right allergen for NPT is particularly difficult in poly-sensitized patients with seasonal allergic rhinitis (SAR). Predictors of NPT outcomes may facilitate the proper use of this test or even substitute it.

Objective

To identify predictors of grass pollen NPT outcome from an array of clinical data, e-diary outcomes, and allergy test results in poly-sensitized pediatric patients with SAR.

Methods

Poly-sensitized, SAR patients with grass pollen allergy, participating in the @IT.2020 pilot project in Rome and Pordenone (Italy), participated in a baseline (T0) visit with questionnaires, skin prick testing (SPT), and blood sampling to measure total (ImmunoCAP, TFS, Sweden) and specific IgE antibodies to grass pollen extracts and their major allergenic molecules (ESEP, Euroimmun Labordiagnostika, Germany). During the pollen season, patients filled the AllergyMonitor® e-diary app measuring their symptoms, medication intake, and allergy-related well-being via the Visual Analogue Scale (VAS). After the pollen season (T1), patients answered clinical questionnaires and underwent a nasal provocation test (NPT) with grass pollen extract.

Results

We recruited 72 patients (age 14.3 ± 2.8 years, 46 males) sensitized to grass and/or other pollens, including olive (63; 87.5%) and pellitory (49; 68.1%). Patients positive to grass pollen NPT (61; 84.7%), compared to the negative ones, had worse VAS values in the e-diary, larger SPT wheal reactions, and higher IgE levels, as well as specific activity to timothy and Bermuda grass extracts, rPhl p 5 and nCyn d 1. A positive NPT to grass pollen was predicted by an index combining the specific activity of IgE towards Phl p 5 and Cyn d 1 (AUC: 0.82; p < 0.01; best cut-off ≥7.25%, sensitivity 70.5%, specificity: 90.9%). VAS results also predicted NPT positivity, although with less precision (AUC: 0.77, p < 0.01; best cut-off ≥7, sensitivity: 60.7%, specificity: 81.8%).

Conclusions

An index combining the specific activity of IgE to rPhl p 5 and nCyn d 1 predicted with moderate sensitivity and high specificity the outcome of a grass pollen NPT in complex, poly-sensitized pediatric patients with seasonal allergic rhinitis. Further studies are needed to improve the index sensitivity and to assess its usefulness for NPT allergen selection or as an alternative to this demanding test procedure.

Nonallergic Rhinitis, Allergic Rhinitis, and Immunotherapy: Advances in the Last Decade

Chronic rhinitis encompassing both allergic and nonallergic rhinitis affects a significant portion of the population worldwide, having a great impact on patient quality of life, and associated comorbid conditions, with an important societal economic burden. Allergists are often the first to evaluate and treat allergic and nonallergic rhinitis, addressing the individual triggers of the disease as well as the patient-specific responses to these triggers. This review focuses on the advances that have been made in the diagnosis, management, and treatment of nonallergic and allergic rhinitis over the past 10 years, including specific allergen immunotherapy, care pathways, and digital health.

Real-world data using mHealth apps in rhinitis, rhinosinusitis and their multimorbidities

Digital health is an umbrella term which encompasses eHealth and benefits from areas such as advanced computer sciences. eHealth includes mHealth apps, which offer the potential to redesign aspects of healthcare delivery. The capacity of apps to collect large amounts of longitudinal, real-time, real-world data enables the progression of biomedical knowledge. Apps for rhinitis and rhinosinusitis were searched for in the Google Play and Apple App stores, via an automatic market research tool recently developed using JavaScript. Over 1500 apps for allergic rhinitis and rhinosinusitis were identified, some dealing with multimorbidity. However, only six apps for rhinitis (AirRater, AllergyMonitor, AllerSearch, Husteblume, MASK-air and Pollen App) and one for rhinosinusitis (Galenus Health) have so far published results in the scientific literature. These apps were reviewed for their validation, discovery of novel allergy phenotypes, optimisation of identifying the pollen season, novel approaches in diagnosis and management (pharmacotherapy and allergen immunotherapy) as well as adherence to treatment. Published evidence demonstrates the potential of mobile health apps to advance in the characterisation, diagnosis and management of rhinitis and rhinosinusitis patients.

Medication Adherence to Intranasal Corticosteroids in Allergic Rhinitis Patients with Comorbid Medical Conditions

Background: To determine medication adherence to intranasal corticosteroid spray (INCS) among allergic rhinitis (AR) patients with comorbid medical conditions. Methods: A cross-sectional study was conducted. Adults above 18 years old with persistent symptoms of AR and comorbid physician-diagnosed asthma, eczema, diabetes mellitus (DM) and hypertension (HPT) were included. The severity of symptoms was assessed by the total nasal symptom score (TNSS), medication adherence was based on the patients’ diaries and barriers to adherence were analyzed by the Brief Medication Questionnaire. Results: 185 participants were enrolled. The medication adherence was 58.9%. Medication adherence was significantly superior in participants with elevated total serum immunoglobulin E (IgE) (χ2 = 8.371, p < 0.05), house dust mite (HDM) allergy to Dermatophagoides pteronyssinus (DP) type (χ2 = 5.149, p < 0.05) and severe TNSS at the first visit (χ2 = 37.016, p < 0.05). Adherence was twice more likely in DP allergy, 2.7 times more likely in elevated total IgE and 15 times more likely in severe TNSS at the first visit. Among the barriers to adherence was lack of symptoms, taking medication only when necessary, fear of adverse effects, running out of medication, experiencing bothersome effects, ineffective response, forgetfulness and taking too many medications. Only lack of symptoms, taking medication when symptomatic, fear of adverse effects and running out of medication were significant. No significant association was found between asthma/eczema (χ2 = 0.418, p > 0.05), HPT/DM (χ2 = 0.759, p > 0.05) and multi-medicine use (χ2 = 1.027, p > 0.05) with medication adherence. Conclusions: Patients having AR with severe nasal symptoms at first presentation, who are sensitized to DP HDM and who have elevated total serum IgE levels have a higher adherence to INCS use. The use of multiple medicines had no impact on the adherence to INCS. As a lack of symptoms was a barrier towards adherence, the benefits of using INCS according to the prescribed dose and frequency must be emphasized to patients with mild and moderate AR at each medical visit. A good rapport between patients and their health care providers is needed to build trust and overcome the barriers, particularly to allay the fears of adverse effects of INCS. The other barriers, such as running out of supply, can be overcome by posting medications directly to patients by the healthcare providers.

Digital Coaching Using Smart Inhaler Technology to Improve Asthma Management in Patients With Asthma in Italy: Community-Based Study

BACKGROUND

Reliance on short-acting β-2 agonists and nonadherence to maintenance medication are associated with poor clinical outcomes in asthma. Digital health solutions could support optimal medication use and therefore disease control in patients with asthma; however, their use in community settings has not been determined.

OBJECTIVE

The primary objective of this study is to investigate community implementation of the Turbu+ program designed to support asthma self-management, including adherence to budesonide and formoterol (Symbicort) Turbuhaler, a combination inhaler for both maintenance therapy or maintenance and reliever therapy. The secondary objective is to provide health care professionals with insights into how patients were using their medication in real life.

METHODS

Patients with physician-diagnosed asthma were prescribed budesonide and formoterol as maintenance therapy, at a dose of either 1 inhalation twice daily (1-BID) or 2 inhalations twice daily (2-BID), or as maintenance and reliever therapy (1-BID and reliever or 2-BID and reliever in a single inhaler), and they received training on Turbu+ in secondary care centers across Italy. An electronic device attached to the patients' inhaler for ≥90 days (data cutoff) securely uploaded medication use data to a smartphone app and provided reminders, visualized medication use, and motivational nudge messages. Average medication adherence was defined as the proportion of daily maintenance inhalations taken as prescribed (number of recorded maintenance actuations per day or maintenance inhalations prescribed per day) averaged over the monitoring period. The proportion of adherent days was defined as the proportion of days when all prescribed maintenance inhalations were taken on a given day. The Wilcoxon test was used to compare the proportion of adherent days between patients in the maintenance regimen and patients in the maintenance and reliever regimen of a given dose.

RESULTS

In 661 patients, the mean (SD) number of days monitored was 217.2 (SD 109.0) days. The average medication adherence (maintenance doses taken/doses prescribed) was 70.2% (108,040/153,820) overall and was similar across the groups (1-BID: 6332/9520, 66.5%; 1‑BID and reliever: 43,578/61,360, 71.0%; 2-BID: 10,088/14,960, 67.4%; 2-BID and reliever: 48,042/67,980, 70.7%). The proportion of adherent days (prescribed maintenance doses/doses taken in a given day) was 56.6% (31,812/56,175) overall and was higher with maintenance and reliever therapy (1-BID and reliever vs 1-BID: 18,413/30,680, 60.0% vs 2510/4760, 52.7%; P<.001; 2-BID and reliever vs 2-BID: 8995/16,995, 52.9% vs 1894/3740, 50.6%; P=.02). Rates of discontinuation from the Turbu+ program were significantly lower with maintenance and reliever therapy compared with maintenance therapy alone (P=.01).

CONCLUSIONS

Overall, the high medication adherence observed during the study might be attributed to the electronic monitoring and feedback mechanism provided by the Turbu+ program.

Automatic market research of mobile health apps for the self-management of allergic rhinitis

BACKGROUND

Only a small number of apps addressing allergic rhinitis (AR) patients have been evaluated. This makes their selection difficult. We aimed to introduce a new approach to market research for AR apps, based on the automatic screening of Apple App and Google Play stores.

METHODS

A JavaScript programme was devised for automatic app screening, and applied in a market assessment of AR self-management apps. We searched the Google Play and Apple App stores of three countries (USA, UK and Australia) with the following search terms: "hay fever", "hayfever", "asthma", "rhinitis", "allergic rhinitis". Apps were eligible if symptoms were evaluated. Results obtained with the automatic programme were compared to those of a blinded manual search. As an example, we used the search to assess apps that can be used to design a combined medication score for AR.

RESULTS

The automatic search programme identified 39 potentially eligible apps out of a total of 1593 retrieved apps. Each of the 39 apps was individually checked, with 20 being classified as relevant. The manual search identified 19 relevant apps (out of 6750 screened apps). Combining both methods, a total of 21 relevant apps were identified, pointing to a sensitivity of 95% and a specificity of 99% for the automatic method. Among these 21 apps, only two could be used for the combined symptom-medication score for AR.

CONCLUSIONS

The programmed algorithm presented herein is able to continuously retrieve all relevant AR apps in the Apple App and Google Play stores, with high sensitivity and specificity. This approach has the potential to unveil the gaps and unmet needs of the apps developed so far.

Applicability of the MASK-Air® App to Severe Asthma Treated with Biologic Molecules: A Pilot Study

MASK-air^®, a good practice of the DG Santé, has been fully validated in allergic rhinitis, but little is known about its applicability to asthmatics. We explored whether the MASK-air^® application is applicable to patients with severe asthma. Severe asthmatics were proposed to use the MASK-air^® application for 6 months, along with best practice treatment. Treatment of the patients was not changed based on the application results. The evolution of the visual analogue scales (VAS) for asthma, shortness of breath, rhinitis, conjunctivitis, work, and sleep was monitored using MASK-air^®. Adherence to MASK-air^® and to the asthma treatment was also checked. Thirteen patients reported on 1229 days of MASK-air^® use. The average application adherence was 51.8% (range: 19.7–98.9%). There was no correlation between application and medication adherence. Highly variably trends were found for the VAS for asthma. Five patients had over 90% well-controlled days, four had well- or moderately controlled asthma (with up to 20% uncontrolled days), one patient had moderately controlled asthma with approximately 20% uncontrolled days, and one patient had 80% uncontrolled days. Highly significant correlations were found for the VAS for asthma, and other patients reported VASs for work, dyspnea, sleep, and rhinitis. MASK-air^® can be used in patients with severe asthma. VAS asthma appears to be an interesting patient-reported outcome highly correlated with dyspnea and impacts on work. Adherence to the application was better than that for rhinitis, but it needs to be improved.

Validation Parameters of Patient-Generated Data for Digitally Recorded Allergic Rhinitis Symptom and Medication Scores in the @IT.2020 Project: Exploratory Study

Background

Mobile health technologies enable allergists to monitor disease trends by collecting daily patient-reported outcomes of allergic rhinitis. To this end, patients with allergies are usually required to enter their symptoms and medication repetitively over long time periods, which may present a risk to data completeness and quality in the case of insufficient effort reporting. Completeness of patient’s recording is easily measured. In contrast, the intrinsic quality and accuracy of the data entered by the patients are more elusive.

Objective

The aim of this study was to explore the association of adherence to digital symptom recording with a predefined set of parameters of the patient-generated symptom and medication scores and to identify parameters that may serve as proxy measure of the quality and reliability of the information recorded by the patient.

Methods

The @IT.2020 project investigates the diagnostic synergy of mobile health and molecular allergology in patients with seasonal allergic rhinitis. In its pilot phase, 101 children with seasonal allergic rhinitis were recruited in Rome and instructed to record their symptoms, medication intake, and general conditions daily via a mobile app (AllergyMonitor) during the relevant pollen season. We measured adherence to daily recording as the percentage of days with data recording in the observation period. We examined the patient’s trajectories of 3 disease indices (Rhinoconjunctivitis Total Symptom Score [RTSS], Combined Symptom and Medication Score [CSMS], and Visual Analogue Scale [VAS]) as putative proxies of data quality with the following 4 parameters: (1) intravariation index, (2) percentage of zero values, (3) coefficient of variation, and (4) percentage of changes in trend. Lastly, we examined the relationship between adherence to recording and each of the 4 proxy measures.

Results

Adherence to recording ranged from 20% (11/56) to 100% (56/56), with 64.4% (65/101) and 35.6% (36/101) of the patients’ values above (highly adherent patients) or below (low adherent patients) the threshold of 80%, respectively. The percentage of zero values, the coefficient of variation, and the intravariation index did not significantly change with the adherence to recording. By contrast, the proportion of changes in trend was significantly higher among highly adherent patients, independently from the analyzed score (RTSS, CSMS, and VAS).

Conclusions

The percentage of changes in the trend of RTSS, CSMS, and VAS is a valuable candidate to validate the quality and accuracy of the data recorded by patients with allergic rhinitis during the pollen season. The performance of this parameter must be further investigated in real-life conditions before it can be recommended for routine use in apps and electronic diaries devoted to the management of patients with allergic rhinitis.

Telemedicine and Telementoring in Rhinology, Otology, and Laryngology: A Scoping Review

Objective

Telemedicine and telementoring have had a significant boost across all medical and surgical specialties over the last decade and especially during the COVID-19 pandemic. The aim of this scoping review is to synthesize the current use of telemedicine and telementoring in otorhinolaryngology and head and neck surgery.

Data Sources

PubMed and Cochrane Library.

Review Methods

A scoping review search was conducted, which identified 469 articles. Following full-text screening by 2 researchers, 173 articles were eligible for inclusion and further categorized via relevant subdomains.

Conclusions

Virtual encounters and telementoring are the 2 main applications of telemedicine in otolaryngology. These applications can be classified into 7 subdomains. Different ear, nose, and throat subspecialties utilized certain telemedicine applications more than others; for example, almost all articles on patient engagement tools are rhinology based. Overall, telemedicine is feasible, showing similar concordance when compared with traditional methods; it is also cost-effective, with high patient and provider satisfaction.

Implications for Practice

Telemedicine in otorhinolaryngology has been widely employed during the COVID-19 pandemic and has a huge potential, especially with regard to its distributing quality care to rural areas. However, it is important to note that with current exponential use, it is equally crucial to ensure security and privacy and integrate HIPAA-compliant systems (Health Insurance Portability and Accountability Act) in the big data era. It is expected that many more applications developed during the pandemic are here to stay and will be refined in years to come.

Development and validation of combined symptom-medication scores for allergic rhinitis

BACKGROUND

Validated combined symptom-medication scores (CSMSs) are needed to investigate the effects of allergic rhinitis treatments. This study aimed to use real-life data from the MASK-air^® app to generate and validate hypothesis- and data-driven CSMSs.

METHODS

We used MASK-air^® data to assess the concurrent validity, test-retest reliability and responsiveness of one hypothesis-driven CSMS (modified CSMS: mCSMS), one mixed hypothesis- and data-driven score (mixed score), and several data-driven CSMSs. The latter were generated with MASK-air^® data following cluster analysis and regression models or factor analysis. These CSMSs were compared with scales measuring (i) the impact of rhinitis on work productivity (visual analogue scale [VAS] of work of MASK-air^® , and Work Productivity and Activity Impairment: Allergy Specific [WPAI-AS]), (ii) quality-of-life (EQ-5D VAS) and (iii) control of allergic diseases (Control of Allergic Rhinitis and Asthma Test [CARAT]).

RESULTS

We assessed 317,176 days of MASK-air^® use from 17,780 users aged 16-90 years, in 25 countries. The mCSMS and the factor analyses-based CSMSs displayed poorer validity and responsiveness compared to the remaining CSMSs. The latter displayed moderate-to-strong correlations with the tested comparators, high test-retest reliability and moderate-to-large responsiveness. Among data-driven CSMSs, a better performance was observed for cluster analyses-based CSMSs. High accuracy (capacity of discriminating different levels of rhinitis control) was observed for the latter (AUC-ROC = 0.904) and for the mixed CSMS (AUC-ROC = 0.820).

CONCLUSION

The mixed CSMS and the cluster-based CSMSs presented medium-high validity, reliability and accuracy, rendering them as candidates for primary endpoints in future rhinitis trials.

Heterogeneous validity of daily data on symptoms of seasonal allergic rhinitis recorded by patients using the e-diary AllergyMonitor®

BACKGROUND

Patient-generated symptom and medication scores are essential for diagnostic and therapeutic decisions in seasonal allergic rhinitis (SAR). Previous studies have shown solid consistencies between different scores at population level in real-life data and trials. For clinicians, the evaluation of individual data quality over time is essential to decide whether to rely on these data in clinical decision-making.

OBJECTIVE

To analyze the consistency of different symptom (SS) and symptom medication scores (SMSs) at individual level in two study cohorts with different characteristics and explore individual patient trajectories over time.

METHODS

Within the pilot phase of the @IT.2020 project on diagnostic synergy of mobile health and molecular IgE assessment in patients with SAR, we analyzed data of 101 children and 93 adults with SAR and instructed them to record their symptoms and medication intake daily via the mobile app AllergyMonitor®. We then assessed the correlation between different SMS and a visual analogue scale (VAS) on the impact of allergy symptoms on daily life at population and individual level.

RESULTS

At population level, the Rhinoconjunctivitis total symptom score (RTSS) correlated better with VAS than the combined symptom and medication score (CSMS). At individual level, consistency among RTSS and VAS was highly heterogeneous and unrelated to disease severity or adherence to recording. Similar heterogeneity was observed for CSMS and VAS.

CONCLUSIONS

The correlation of clinical information provided by different disease severity scores based on data collected via electronic diaries (e-diaries), is sufficient at population level, but broadly heterogeneous for individual patients. Consistency of the recorded data must be examined for each patient before remotely collected information is used for clinical decision making.

The impact of a digital wheeze detector on parental disease management of pre-school children suffering from wheezing-a pilot study

BACKGROUND

Viral airway infections are a major reason for doctor's visits at pre-school age, especially when associated with wheezing. While proper treatment requires adequate recognition of airway obstruction, caretakers are often struggling with this judgment, consequently leading to insufficient or late treatment and an unnecessary discomfort of the patient. Digital technologies may serve to support parental decision taking. The aim of the present pilot study is to acquire data on the feasibility of recruitment and observation procedures for a randomized controlled trial on the impact of a digital wheeze detector in a home management setting of pre-school wheezing.

METHODS

This single-armed pilot study enrolled patients with a doctor's diagnosis of wheezing aged 9 to 72 months. Participants were asked to use a digital wheeze detector (WheezeScan, Omron Healthcare, Japan) 2×/day for 30 days and record the child's respiratory symptoms, detection of wheezing, and medication intake via an electronic diary (eDiary) app. Demographic and clinical data were collected at the recruitment visit. The asthma control test and the Parent Asthma Management Self-Efficacy Scale (PAMSES) were assessed both, at recruitment and follow-up.

RESULTS

Twenty families were recruited and completed the monitoring. All but one completed the follow-up after 30 days. The recruitment procedures were feasible, and adherence to daily monitoring reached an average of 81%. The use of the wheeze detector was rated as uncomplicated. Parents detected wheezing without digital support in only 22/708 (3.1%) of the recorded events. By contrast, the wheeze detector indicated an airway obstruction in 140/708 (19.8%) of the recordings.

CONCLUSION

In parallel to feasible recruitment procedures, we observed good usability of the wheeze detection device and high adherence to eDiary recording. The positive outcomes show that the WheezeScan may empower parents by increasing their capacity for wheeze detection. This deserves to be investigated in a larger randomized controlled trial.

Validity, reliability, and responsiveness of daily monitoring visual analog scales in MASK-air®

Background

MASK-air® is an app that supports allergic rhinitis patients in disease control. Users register daily allergy symptoms and their impact on activities using visual analog scales (VASs). We aimed to assess the concurrent validity, reliability, and responsiveness of these daily VASs.

Methods

Daily monitoring VAS data were assessed in MASK-air® users with allergic rhinitis. Concurrent validity was assessed by correlating daily VAS values with those of the EuroQol-5 Dimensions (EQ-5D) VAS, the Control of Allergic Rhinitis and Asthma Test (CARAT) score, and the Work Productivity and Activity Impairment Allergic Specific (WPAI-AS) Questionnaire (work and activity impairment scores). Intra-rater reliability was assessed in users providing multiple daily VASs within the same day. Test-retest reliability was tested in clinically stable users, as defined by the EQ-5D VAS, CARAT, or "VAS Work" (i.e., VAS assessing the impact of allergy on work). Responsiveness was determined in users with two consecutive measurements of EQ-5D-VAS or "VAS Work" indicating clinical change.

Results

A total of 17,780 MASK-air® users, with 317,176 VAS days, were assessed. Concurrent validity was moderate-high (Spearman correlation coefficient range: 0.437-0.716). Intra-rater reliability intraclass correlation coefficients (ICCs) ranged between 0.870 (VAS assessing global allergy symptoms) and 0.937 (VAS assessing allergy symptoms on sleep). Test-retest reliability ICCs ranged between 0.604 and 0.878-"VAS Work" and "VAS asthma" presented the highest ICCs. Moderate/large responsiveness effect sizes were observed-the sleep VAS was associated with lower responsiveness, while the global allergy symptoms VAS demonstrated higher responsiveness.

Conclusion

In MASK-air®, daily monitoring VASs have high intra-rater reliability and moderate-high validity, reliability, and responsiveness, pointing to a reliable measure of symptom loads.

Electro-optical classification of pollen grains via microfluidics and machine learning

In aerobiological monitoring and agriculture there is a pressing need for accurate, label-free and automated analysis of pollen grains, in order to reduce the cost, workload and possible errors associated to traditional approaches. Methods: We propose a new multimodal approach that combines electrical sensing and optical imaging to classify pollen grains flowing in a microfluidic chip at a throughput of 150 grains per second. Electrical signals and synchronized optical images are processed by two independent machine learning-based classifiers, whose predictions are then combined to provide the final classification outcome. Results: The applicability of the method is demonstrated in a proof-of-concept classification experiment involving eight pollen classes from different taxa. The average balanced accuracy is 78.7 % for the electrical classifier, 76.7 % for the optical classifier and 84.2 % for the multimodal classifier. The accuracy is 82.8 % for the electrical classifier, 84.1 % for the optical classifier and 88.3 % for the multimodal classifier. Conclusion: The multimodal approach provides better classification results with respect to the analysis based on electrical or optical features alone. Significance: The proposed methodology paves the way for automated multimodal palynology. Moreover, it can be extended to other fields, such as diagnostics and cell therapy, where it could be used for label-free identification of cell populations in heterogeneous samples.

Investigating the Use of Electronic Well-being Diaries Completed Within a Psychoeducation Program for University Students: Longitudinal Text Analysis Study

Background

Psychoeducation has the potential to support students experiencing distress and help meet the demand for support; however, there is a need to understand how these programs are experienced. Web-based diaries are a useful activity for psychoeducation because of their therapeutic benefits, ability to capture naturalistic data relevant to well-being, and appropriateness for text analysis methods.

Objective

This study aims to examine how university students use electronic diaries within a psychoeducation program designed to enhance mental well-being.

Methods

The Science of Happiness course was administered to 154 undergraduate students in a university setting (the United Kingdom). Diaries were collected from the students for 9 weeks. Baseline well-being data were collected using the Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS). The percentage of negative and positive emotion words used in diaries (emotional tone) and use of words from five life domains (social, work, money, health, and leisure) were calculated using the Linguistic Inquiry and Word Count 2015 software. Random effects (generalized least squares) regression models were estimated to examine whether time, diary characteristics, demographics, and baseline well-being predict the emotional tone of diaries.

Results

A total of 149 students participated in the diary study, producing 1124 individual diary entries. Compliance with the diary task peaked in week 1 (n=1041, 92.62%) and was at its lowest in week 3 (n=807, 71.81%). Compared with week 1, diaries were significantly more positive in their emotional tone during week 5 (mean difference 23.90, 95% CI 16.89-30.90) and week 6 (mean difference 26.62, 95% CI 19.35-33.88) when students were tasked with writing about gratitude and their strengths. Across weeks, moderate and high baseline SWEMWBS scores were associated with a higher percentage of positive emotion words used in diaries (increases compared with students scoring low in SWEMWBS were 5.03, 95% CI 0.08-9.98 and 7.48, 95% CI 1.84-13.12, respectively). At week 1, the diaries of students with the highest levels of baseline well-being (82.92, 95% CI 73.08-92.76) were more emotionally positive on average than the diaries of students with the lowest levels of baseline well-being (59.38, 95% CI 51.02-67.73). Diaries largely focused on the use of social words. The emotional tone of diary entries was positively related to the use of leisure (3.56, 95% CI 2.28-4.85) and social words (0.74, 95% CI 0.21-1.27), and inversely related to the use of health words (−1.96, 95% CI −3.70 to −0.22).

Conclusions

We found evidence for short-term task-specific spikes in the emotional positivity of web-based diary entries and recommend future studies examine the possibility of long-term impacts on the writing and well-being of students. With student well-being strategies in mind, universities should value and encourage leisure and social activities.

The Role of Mobile Health Technologies in Stratifying Patients for AIT and Its Cessation: The ARIA-EAACI Perspective

Allergen immunotherapy (AIT) is a proven therapeutic option for the treatment of allergic rhinitis and/or asthma. Many international or national practice guidelines have been produced, but the evidence-based method varies and they do not usually propose care pathways. The present article considers the possible role of mobile health in AIT for allergic rhinitis/asthma. There are no currently available validated biologic biomarkers that can predict AIT success, and mobile health biomarkers have some relevance. In the current article, the following aspects will be discussed: patient stratification for AIT, symptom-medication scores for the follow-up of patients, clinical trials, as well as the approach of the European Academy of Allergy and Clinical Immunology.

New medical big data for P4 medicine on allergic conjunctivitis

Allergic conjunctivitis affects approximately 15-20% of the global population and can permanently deteriorate one's quality of life (QoL) and work productivity, leading to societal work force costs. Although not fully understood, allergic conjunctivitis is a multifactorial disease with a complex network of environmental, lifestyle, and host contributory risk factors. To effectively enhance the quality of treatment for patients with allergic conjunctivitis, as well as other allergic diseases, the field must first comprehend the pathology underlying various individualized subjective symptoms and stratify the disease according to risk factors and presentations. Such competent stratification and societal reconstruction that targets the alleviation of the damage due to allergic diseases would greatly help ramify personalized treatments and prevent the projected increase in societal costs imposed by allergic diseases. Owing to the rapid advancements in the information and technology sector, medical big data are greatly accessible and useful to decipher the pathophysiology of many diseases. Such data collected through multi-omics and mobile health have been effective for research on chronic diseases including allergic and immune-mediated diseases. Novel big data containing vast and continuous information on individuals with allergic conjunctivitis and other allergic symptoms are being used to search for causative genes of diseases, gain insights into new biomarkers, prevent disease progression, and, ultimately, improve QoL. The individualized and holistic data accrued from new angles using technological innovations are helping the field realize the principles of P4 medicine: predictive, preventive, personalized, and participatory medicine.

The Potential of Clinical Decision Support Systems for Prevention, Diagnosis, and Monitoring of Allergic Diseases

Clinical decision support systems (CDSS) aid health care professionals (HCP) in evaluating large sets of information and taking informed decisions during their clinical routine. CDSS are becoming particularly important in the perspective of precision medicine, when HCP need to consider growing amounts of data to create precise patient profiles for personalized diagnosis, treatment and outcome monitoring. In allergy care, several CDSS are being developed and investigated, mainly for respiratory allergic diseases. Although the proposed solutions address different stakeholders, the majority aims at facilitating evidence-based and shared decision-making, incorporating guidelines, and real-time clinical data. We offer here an overview on existing tools, new developments and novel concepts and discuss the potential of digital CDSS in improving prevention, diagnosis and monitoring of allergic diseases.

Current and emerging pharmacotherapy for pediatric allergic rhinitis

INTRODUCTION

Allergic rhinitis (AR) is a global health problem in adults as well as the younger population, continuously increasing and posing a significant problem for patients, health care systems and economies. For the younger population, some aspects differ from treatment of adults, namely, prevention, compliance and adherence.

AREAS COVERED

This narrative review summarizes all the pharmacotherapeutic options with special focus on the pediatric population. Moreover, it elucidates prevention strategies as well as future developments of AR treatment. Currently, symptomatic therapy in the form of steroids and antihistamines is applied topically and systemically where steroids need to be administered with caution and for a very short term. The only disease-modifying and causal treatment is allergen immunotherapy administered sublingually and subcutaneously. Future and current novel therapeutic options are human monoclonal antibodies.

EXPERT OPINION

The greatest potential for future developments currently lie in allergen immunotherapy and here in different routes of administration and modification of (recombinant) allergens as well as immune-modulating adjuvants and nanoparticles. Secondly, monoclonal antibodies are promising molecules blocking and/or interfering with up- and downstream immune mechanisms. Another important aspect lies in prevention of allergic sensitization and disease progression through both AIT and biologics which is particularly true for the pediatric population.

Digital technologies for an improved management of respiratory allergic diseases: 10 years of clinical studies using an online platform for patients and physicians

Background

Digital health technologies carry the great potential of assisting physicians in making well-informed diagnostic and therapeutic decisions. In allergy care, electronic clinical diaries have been recently used to prospectively collect patient data and improve diagnostic precision.

Objective

This review summarizes the clinical and scientific experience we gathered over 10 years of using a digital platform for patients suffering from seasonal allergic rhinitis.

Methods

The mobile application and back-office of AllergyMonitor (TPS software production, Rome, Italy) enable patients to record their daily allergy symptoms as well as drug and immunotherapy intake plus possible side effects in a customizable way. The results can be accessed by the patient and attending physician as concise reports via a smartphone or computer. This technology has been used in several clinical studies and routine practice since 2009.

Results

Our studies showed that A) the etiological diagnosis of SAR may be supported by matching prospectively registered symptoms with pollen counts; B) it is possible to perform a short-term prediction of SAR-symptoms at individual level; C) the adherence to daily symptom monitoring can remain high (> 80%) throughout several weeks when prescribed and thoroughly explained by the treating doctor; D) the use of mobile technology can improve adherence to symptomatic drugs as well as allergen-specific immunotherapy and E) the choice of the correct symptom-severity-score is critical at patient level, but not at group level.

Conclusion

The studies and clinical practice based on the use of AllergyMonitor have proven the reliability and positive impact of a digital platform including an electronic diary (eDiary) on the diagnostic precision of SAR in poly-sensitized patients as well as patient adherence to both, drug therapy and allergen immunotherapy.