Palivizumab prophylaxis, respiratory syncytial virus and subsequent development of asthma

Respiratory-syncytial virus immunoprophylaxis on asthma symptoms development in prematurity with bronchopulmonary dysplasia

Background

Infants with respiratory-syncytial virus bronchiolitis hospitalization are more likely to develop wheezing and subsequent asthma. Reportedly, palivizumab prophylaxis effectively prevents respiratory-syncytial virus hospitalization in high-risk children-such as premature infants or infants with bronchopulmonary dysplasia (BPD).

Objective

We sought to explore the effect of respiratory-syncytial virus immunoprophylaxis on the risk of asthma development in premature infants with BPD in subtropical areas.

Methods

This case-control study included preterm children with BPD born at Mackay Memorial Hospital, Taipei, Taiwan, from 1999 to 2015. Overall, medical records of 616 eligible participants were retrospectively collected from their birth to the time they attained an age of 5 to 20 years. The primary outcome was onset of active asthma.

Results

Overall, 576 consecutive cases met the inclusion criteria. Of these, 306 (53.2%) patients had palivizumab exposure and 191 (33.2%) were diagnosed with asthma. Patients with history of respiratory-syncytial virus bronchiolitis hospitalization had a higher risk of developing asthma in the future (adjusted odds ratio, 3.77; 95% CI, 2.30-6.20, P < .001; hazard ratio, 2.56; 95% CI, 1.81-3.62, P < .001). Palivizumab prophylaxis reduced future asthma development through the inhibition of respiratory-syncytial virus bronchiolitis hospitalization (coefficient, -0.021; 95% CI, -0.031 to -0.011, P = .027). Asthmatic children who received palivizumab immunoprophylaxis had a lesser active asthma duration than those who did not (P = .005).

Conclusions

Children with BPD with hospitalization for respiratory-syncytial virus bronchiolitis had higher risk of developing asthma compared with those without respiratory-syncytial virus infection. Prophylactic palivizumab might reduce later asthma development through inhibition of respiratory-syncytial virus bronchiolitis hospitalization. For those already developing asthma, palivizumab could reduce active asthma duration.

Are Babies Born Preterm High-Risk Asthma Candidates?

Among preterm infants, the risk of developing asthma is a matter of debate. This review discusses the state of the art of poorly understood prematurity-associated asthma. Impaired pulmonary function is common in children born prematurely. Preterm infants are prone to developing viral respiratory tract infections, bronchiolitis in the first year of life, and recurrent viral wheezing in preschool age. All of these conditions may precede asthma development. We also discuss the role of both atopic sensitization and intestinal microbiome and, consequently, immune maturation. Diet and pollution have been considered to better understand how prematurity could be associated with asthma. Understanding the effect of factors involved in asthma onset may pave the way to improve the prediction of this asthma phenotype.

Alternative Routes of Administration for Therapeutic Antibodies—State of the Art

Background: For the past two decades, there has been a huge expansion in the development of therapeutic antibodies, with 6 to 10 novel entities approved each year. Around 70% of these Abs are delivered through IV injection, a mode of administration allowing rapid and systemic delivery of the drug. However, according to the evidence presented in the literature, beyond the reduction of invasiveness, a better efficacy can be achieved with local delivery. Consequently, efforts have been made toward the development of innovative methods of administration, and in the formulation and engineering of novel Abs to improve their therapeutic index. Objective: This review presents an overview of the routes of administration used to deliver Abs, different from the IV route, whether approved or in the clinical evaluation stage. We provide a description of the physical and biological fundamentals for each route of administration, highlighting their relevance with examples of clinically-relevant Abs, and discussing their strengths and limitations. Methods: We reviewed and analyzed the current literature, published as of the 1 April 2022 using MEDLINE and EMBASE databases, as well as the FDA and EMA websites. Ongoing trials were identified using clinicaltrials.gov. Publications and data were identified using a list of general keywords. Conclusions: Apart from the most commonly used IV route, topical delivery of Abs has shown clinical successes, improving drug bioavailability and efficacy while reducing side-effects. However, additional research is necessary to understand the consequences of biological barriers associated with local delivery for Ab partitioning, in order to optimize delivery methods and devices, and to adapt Ab formulation to local delivery. Novel modes of administration for Abs might in fine allow a better support to patients, especially in the context of chronic diseases, as well as a reduction of the treatment cost.

Early Life Factors Associated with Preschool Wheezing in Preterm Infants

Advanced neonatal care has increased the survival of neonates born prematurely, and prematurity is a well-known risk factor for asthma/wheezing disorders. Thus, this prospective study aimed to determine the early life factors associated with preschool wheezing in premature neonates. Preterm neonates born between 2012 and 2017 were recruited, excluding those with bacterial infection within 7 days of life, maternal sepsis, and maternal chorioamnionitis. Birth and admission history, comorbidities, and maternal history were documented. Respiratory problems were followed-up at the neonatal outpatient department. Patients were divided into wheezing and non-wheezing groups. Data were analyzed using the Mann-Whitney test and Fisher's exact test, and multivariable logistic regression was used to define the risk factors of preschool wheezing/asthma. A total of 125 preterm infants were enrolled, including 19 in the wheezing group and 106 in the non-wheezing group. Patients in the wheezing group had longer duration of intubation (p = 0.025), higher rates for exclusive breast milk feeding (p = 0.012), and higher re-hospitalization rates for respiratory tract infections (p < 0.001), especially for respiratory syncytial virus (RSV) bronchiolitis (p = 0.045). The incidence of allergic rhinitis was also higher in the wheezing group (p = 0.005). After multivariable logistic regression, allergic rhinitis and re-hospitalization for respiratory tract infections were two significant risk factors for preschool wheezing/asthma in premature neonates. Close follow-up of premature infants at high risk for asthma susceptibility is recommended.

The Age, Sex, and Geographical Distribution of Self-Reported Asthma Triggers on Children With Asthma in China

Background: Asthma can be exacerbated by many triggers, and the heterogeneity of asthma triggers is clear among children with asthma. This study describes asthma triggers using a large-scale electronic dataset from the smartphone-based Chinese Children's Asthma Action Plan (CCAAP) app and aims to examine the difference in asthma triggers among different subgroups of children with asthma. Methods: Data from the smartphone-based CCAAP app between February 22, 2017, and November 23, 2020, were reviewed, and children with asthma who reported their asthma triggers were enrolled. Eight common asthma triggers were listed in the software: upper respiratory infection (URI), allergen sensitization, exercise, emotional disturbances, pungent odors, air pollution/smog, weather change, and tobacco smoke. We compared the incidence of asthma triggers among different subgroups (<6 years vs. 6-17 years; boy vs. girl; eastern region vs. central region vs. western region). Results: We enrolled 6,835 patients with self-reported asthma triggers. When compared by sex, boys had a higher proportion of exercise-triggered asthma than girls (boys vs. girls, 22.5 vs. 19.7%, p < 0.05). The proportion of patients <6 years of age with URI-triggered asthma was higher than that of patients 6-17 years of age (<6 vs. 6-17 years, 80.9 vs. 74.9%, p < 0.001). Patients 6-17 years of age were more likely than patients <6 years of age to report five of the asthma triggers: allergen sensitization (<6 vs. 6-17 years, 26.6 vs. 35.8%, p < 0.001), exercise (<6 vs. 6-17 years, 19.3 vs. 23.7%, p < 0.001), pungent odors (<6 vs. 6-17 years, 8.8 vs. 12.7%, p < 0.001), air pollution/smog (<6 vs. 6-17 years, 9.4 vs. 16.2%, p < 0.001), and tobacco smoke (<6 vs. 6-17 years, 3.5 vs. 5.3%, p < 0.001). In subgroups based on geographical distribution, asthma triggering of allergen sensitization was reported to be the most common in patients from the eastern region (eastern region vs. central region vs. western region, 35.0 vs. 24.6 vs. 28.0%, p < 0.001). Exercise-triggered asthma was found to be the most prevalent among patients from the central region (eastern region vs. central region vs. western region, 21.6 vs. 24.8 vs. 20.4%, p < 0.05). However, the proportion of patients with air pollution/smog as an asthma trigger was the lowest among those from the western region (eastern region vs. central region vs. western region, 14.1 vs. 14.1 vs. 10.8%, p < 0.05). Conclusion: Children with asthma present different types of asthma triggers, both allergenic and nonallergenic. Age, sex, and geographical distribution affect specific asthma triggers. Preventive measures can be implemented based on a patient's specific asthma trigger.

Respiratory syncytial virus prophylaxis for prevention of recurrent childhood wheeze and asthma: a systematic review

BACKGROUND

Acute bronchiolitis caused by respiratory syncytial virus (RSV) has been associated with greater risk of recurrent wheezing and asthma. However, it is unclear whether this association is causal. RSV-specific monoclonal antibodies have been shown to reduce RSV-related hospitalisations in high-risk infants, but the longer-term follow-up has given conflicting evidence for prevention of recurrent wheeze or asthma.

OBJECTIVE

We performed a systematic review and meta-analysis to determine whether monoclonal antibody prophylaxis against RSV bronchiolitis reduces the risk of subsequent recurrent wheeze or asthma. If so, this may support the hypothesis of causality.

METHODS

Studies were identified via an online database search using Embase, MEDLINE, PubMed, Web of Science and the Cochrane Library. Manufacturers of monoclonal antibodies were contacted directly for unpublished data. The intervention of interest was RSV monoclonal antibody prophylaxis, and the primary outcome measure was recurrent wheeze and/or asthma. Studies were screened according to inclusion/exclusion criteria. Included studies were evaluated for quality and assessed for bias independently by 3 reviewers using the 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) approach. Results were extracted into 2 × 2 outcome tables and a meta-analysis carried out producing forest plots based on relative risk. Heterogeneity was assessed using the I2 statistic.

RESULTS

The search identified 141 articles, which, after screening, resulted in eight studies (2 randomised controlled trials), thus including 11,195 infants in the meta-analysis. The overall result demonstrated a non-statistically significant reduction in relative risk of developing recurrent wheeze or asthma (RR 0.60; 95% CI 0.31 to 1.16). Study quality was generally low with evidence of publication bias and statistical heterogeneity. However, sub-group analysis excluding studies deemed to be 'very low' quality showed a relative risk of 0.42 (95% CI 0.22 to 0.80, p = 0.008). A further sub-group analysis for infants aged 32 to < 36 weeks showed a statistically significant relative risk of 0.35 (95% CI 0.14 to 0.86, p = 0.02).

DISCUSSION

We did not identify an overall statistically significant benefit. However, our two sub-group analyses did find statistically significant benefits of monoclonal antibody therapy on the risk of recurrent wheeze and asthma. The main limitation of this study is the lack of high-quality randomised controlled trials, highlighting the need for more research in this field.

Direct medical costs of RSV-related bronchiolitis hospitalizations in a middle-income tropical country

INTRODUCTION AND OBJECTIVES

With the objective of making informed decisions on resource allocation, there is a critical need for studies that provide accurate information on hospital costs for treating respiratory syncytial virus (RSV)-related bronchiolitis, mainly in middle-income countries (MICs). The aim of the present study was to evaluate the direct medical costs associated with bronchiolitis hospitalizations caused by infection with RSV in Bogota, Colombia.

MATERIAL AND METHODS

We reviewed the available electronic medical records (EMRs) for all infants younger than two years of age who were admitted to the Fundacion Hospital de La Misericordia with a discharge principal diagnosis of RSV-related bronchiolitis over a 24-month period from January 2016 to December 2017. Direct medical costs of RSV-related bronchiolitis were retrospectively collected by dividing the infants into three groups: those requiring admission to the pediatric ward (PW) only, those requiring admission to the pediatric intermediate care unit (PIMC), and those requiring to the pediatric intensive care unit (PICU).

RESULTS

A total of 89 patients with a median (IQR) age of 7.1 (3.1-12.2) months were analyzed of whom 20 (56.2%) were males. Overall, the median (IQR) cost of infants treated in the PW, in the PIMC, and in the PICU was US$518.0 (217.0-768.9) vs. 1305.2 (1051.4-1492.2) vs. 2749.7 (1372.7-4159.9), respectively, with this difference being statistically significant (p<0.001).

CONCLUSIONS

The present study helps to further our understanding of the economic burden of RSV-related bronchiolitis hospitalizations among infants of under two years of age in a middle-income tropical country.

A 15-Minute Incremental Increase in Operative Duration Is Associated With an Additional Risk of Complications Within 30 Days After Arthroscopic Rotator Cuff Repair

Background:

Operative time is a risk factor for short-term complications after orthopaedic procedures; however, it has yet to be investigated as an independent risk factor for postoperative complications after arthroscopic rotator cuff repair.

Purpose:

To determine whether operative time is an independent risk factor for complications, readmissions, and extended hospital stays within 30 days after arthroscopic rotator cuff repair.

Study Design:

Descriptive epidemiology study.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program was queried for all hospital-based inpatient and outpatient arthroscopic rotator cuff repairs (Current Procedural Terminology code 29827) from 2005 to 2016. Concomitant procedures such as subacromial decompression, biceps tenodesis, superior labrum anterior and posterior (SLAP) repair, labral repair, and distal clavicle excision were also included, whereas patients undergoing arthroplasty were excluded from the study. Operative time was correlated with patient demographics, comorbidities, and concomitant procedures. All adverse events were correlated with operative time, while controlling for the above preoperative variables, using multivariate Poisson regression with a robust error variance.

Results:

A total of 27,524 procedures met inclusion and exclusion criteria. The mean age of patients was 58.4 ± 10.9 years, the mean operative time was 86.9 ± 37.4 minutes, and the mean body mass index was 30.4 ± 7.0 kg/m². Concomitant biceps tenodesis, glenohumeral debridement, SLAP repair, labral repair, and distal clavicle excision significantly increased operative time (P < .001) but not the risk of adverse events (P > .05). The overall rate of adverse events was 0.88%. After adjusting for demographic and procedural characteristics, a 15-minute increase in operative duration was associated with an increased risk of anemia requiring transfusion (relative risk [RR], 1.27 [95% CI, 1.14-1.42]; P < .001), venous thromboembolism (RR, 1.17 [95% CI, 1.02-1.35]; P = .029), surgical site infection (RR, 1.13 [95% CI, 1.03-1.24]; P = .011), and extended length of hospital stay (RR, 1.07 [95% CI, 1.00-1.14]; P = .036).

Conclusion:

Although the rate of short-term complications after arthroscopic rotator cuff repair is low, incremental increases in operative time are associated with an increased risk of adverse events such as surgical site infection, pulmonary embolism, transfusion, and extended length of hospital stay. Efforts should be made to maximize surgical efficiency in the operating room through optimal coordination of the staff or increased preoperative planning.