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Thomas ET, Thomas ST, Perera R, Gill PJ, Moloney S, Heneghan CJ. The quality of paediatric asthma guidelines: evidence underpinning diagnostic test recommendations from a meta-epidemiological study. Fam Pract 2024; 41:460-469. [PMID: 37196169 PMCID: PMC11324322 DOI: 10.1093/fampra/cmad052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Asthma is one of the most frequent reasons children visit a general practitioner (GP). The diagnosis of childhood asthma is challenging, and a variety of diagnostic tests for asthma exist. GPs may refer to clinical practice guidelines when deciding which tests, if any, are appropriate, but the quality of these guidelines is unknown. OBJECTIVES To determine (i) the methodological quality and reporting of paediatric guidelines for the diagnosis of childhood asthma in primary care, and (ii) the strength of evidence supporting diagnostic test recommendations. DESIGN Meta-epidemiological study of English-language guidelines from the United Kingdom and other high-income countries with comparable primary care systems including diagnostic testing recommendations for childhood asthma in primary care. The AGREE-II tool was used to assess the quality and reporting of the guidelines. The quality of the evidence was assessed using GRADE. RESULTS Eleven guidelines met the eligibility criteria. The methodology and reporting quality varied across the AGREE II domains (median score 4.5 out of 7, range 2-6). The quality of evidence supporting diagnostic recommendations was generally of very low quality. All guidelines recommended the use of spirometry and reversibility testing for children aged ≥5 years, however, the recommended spirometry thresholds for diagnosis differed across guidelines. There were disagreements in testing recommendations for 3 of the 7 included tests. CONCLUSIONS The variable quality of guidelines, lack of good quality evidence, and inconsistent recommendations for diagnostic tests may contribute to poor clinician adherence to guidelines and variation in testing for diagnosing childhood asthma.
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Affiliation(s)
- Elizabeth T Thomas
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah T Thomas
- Department of Neurology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter J Gill
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Susan Moloney
- Department of Paediatrics, Gold Coast University Hospital, Southport, Queensland, Australia
- School of Medicine, Griffith University, Gold Coast, Queensland,Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Carl J Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Čibirkaitė A, Bubnaitienė V, Hansted E, Gurskis V, Vaidelienė L. Quality-of-Life Assessment in Children with Mild to Moderate Bronchial Asthma. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:771. [PMID: 38792954 PMCID: PMC11122762 DOI: 10.3390/medicina60050771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 05/26/2024]
Abstract
Background and Objectives: Assess the quality of life of children aged 2-10 with mild to moderate bronchial asthma. To evaluate the general health condition of children with mild and moderate severity bronchial asthma. To determine health changes in children with mild- and moderate-severity bronchial asthma as they grow older. To evaluate the impact of mild- and moderate-severity bronchial asthma on children's daily and social activities, physical health, emotional state, and general well-being. Materials and Methods: A comparative cross-sectional study was conducted in March-June 2020. Parents or guardians of 2-10-year-old children without bronchial asthma and children with mild to moderate bronchial asthma were interviewed after receiving their written informed consent. The questionnaire was based on the standardized quality-of-life quiz SF-36. A total of 248 questionnaires were collected-106 from the parents or guardians of children with bronchial asthma and 142 from parents/guardians of children without bronchial asthma. For further analysis, 106 children without bronchial asthma and with no chronic conditions were selected. Quantitative variables were compared using the Mann-Whitney U test and qualitative data using the chi-square (χ2) criteria. Quantitative data were described by giving means, medians, and standard deviations (SD); qualitative features by giving relative frequencies. Statistical data were analyzed using SPSS and Excel 2020. Results: Children with mild and moderate asthma exhibit poorer health compared to their healthy counterparts. Only 20.7% of respondents with asthma reported excellent or very good health, contrasting with 64.1% of healthy children (p < 0.001). As children with asthma age, their general condition improves, with 46.2% showing improvement in the past year, while 42.5% of healthy children had a stable condition (p < 0.05). In various activities, children with asthma face more constraints than healthy children (p < 0.05), including energetic activities (sick-59.5%; healthy-10.3%), moderate activities (sick-24.5%; healthy-4.7%), climbing stairs (sick-22.7%; healthy-3.8%), and walking over 100 m (sick-9.4%; healthy-0%). Children with asthma are more likely to experience exhaustion, anxiety, tiredness, lack of energy, and restraint in public activities (p < 0.05). Conclusions: Parents/caregivers of children with mild to moderate bronchial asthma rate their health worse than those of healthy children do. As children with mild to moderate bronchial asthma grow, the disease impact on their overall well-being decreases. Children with mild to moderate bronchial asthma, compared to healthy children, experience more limitations in vigorous or moderate activities; face more difficulties climbing stairs or walking more than 100 m; frequently feel exhaustion, anxiety, fatigue, or lack of energy; and encounter restrictions in social activities.
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Affiliation(s)
- Agnė Čibirkaitė
- Department of Pediatrics, Medical Academy, Lithuanian University of Health Sciences, LT 44307 Kaunas, Lithuania; (V.B.); (E.H.); (V.G.); (L.V.)
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Daines L, Donaghy E, Canny A, Murray V, Campbell L, Stonham C, Bush A, McKinstry B, Milne H, Price D, Sheikh A, Pinnock H. Clinician views on how clinical decision support systems can help diagnose asthma in primary care: a qualitative study. J Asthma 2024; 61:377-385. [PMID: 37934476 DOI: 10.1080/02770903.2023.2280839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/02/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE Asthma can be difficult to diagnose in primary care. Clinical decision support systems (CDSS) can assist clinicians when making diagnostic decisions, but the perspectives of intended users need to be incorporated into the software if the CDSS is to be clinically useful. Therefore, we aimed to understand health professional views on the value of an asthma diagnosis CDSS and the barriers and facilitators for use in UK primary care. METHODS We recruited doctors and nurses working in UK primary care who had experience of assessing respiratory symptoms and diagnosing asthma. Qualitative interviews were used to explore clinicians' experiences of making a diagnosis of asthma and understand views on a CDSS to support asthma diagnosis. Interviews were audio-recorded, transcribed verbatim and analyzed thematically. RESULTS 16 clinicians (nine doctors, seven nurses) including 13 participants with over 10 years experience, contributed interviews. Participants saw the potential for a CDSS to support asthma diagnosis in primary care by structuring consultations, identifying relevant information from health records, and having visuals to communicate findings to patients. Being evidence based, regularly updated, integrated with software, quick and easy to use were considered important for a CDSS to be successfully implemented. Experienced clinicians were unsure a CDSS would help their routine practice, particularly in straightforward diagnostic scenarios, but thought a CDSS would be useful for trainees or less experienced colleagues. CONCLUSIONS To be adopted into clinical practice, clinicians were clear that a CDSS must be validated, integrated with existing software, and quick and easy to use.
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Affiliation(s)
- Luke Daines
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Eddie Donaghy
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Anne Canny
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Victoria Murray
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Leo Campbell
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Carol Stonham
- NHS Gloucestershire Integrated Care Board, Gloucester, UK
- Primary Care Respiratory Society (PCRS), Knowle, UK
| | - Andrew Bush
- Imperial Centre for Paediatrics and Child Health and National Heart and Lung Institute, Imperial College, London, UK
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Brian McKinstry
- Centre for Population and Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Heather Milne
- South East GP Unit, NHS Education for Scotland, Edinburgh, UK
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Optimum Patient Care, Cambridge, UK
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Aziz Sheikh
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Hilary Pinnock
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, UK
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Ding H, Shi Z, Lin H, Sun Y, Zhang L, Liu F, Wang X, Zhang Z, Zhang G. Serum proteomics identifies novel diagnostic biomarkers for asthma in preschool children. J Thorac Dis 2024; 16:65-80. [PMID: 38410598 PMCID: PMC10894366 DOI: 10.21037/jtd-23-974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 11/17/2023] [Indexed: 02/28/2024]
Abstract
Background Asthma is characterized by airway hyperresponsiveness, reversible airway obstruction, and chronic airway inflammation. It is the most common chronic disease in childhood. However, the diagnosis of childhood asthma remains challenging, and there is an urgent need to develop new diagnostic methods. Methods To identify biomarkers of asthma in children, we adopted the Orbitrap-based data-independent acquisition (DIA) mass spectrometry proteomics method to analyze the serum proteomic signatures of children with acute asthma and convalescent children. Results We identified 747 proteins in 46 serum samples and 50 differentially expressed proteins (DEPs) that distinguished between asthmatic and healthy children. Next, functional enrichment analysis of the DEPs was conducted, it was indicated that the DEPs were significantly enriched in immune-related and function terms and pathways. Furthermore, we performed statistical analysis and identified MMP14, ABHD12B, PCYOX1, LTBP1, CFHR4, APOA1, IGHG4, ANG and IGFALS proteins as the diagnostic biomarker candidates. Ultimately, a promising asthma diagnostic model for preschool children based on IGFALS was built and evaluated. The area under the curve (AUC) of the IGFALS model was 0.959. Conclusions In this study, the DIA proteome strategy was used and the largest number of proteins of asthmatic children serum proteomics was identified. The proteomics results showed that the DEPs play the central role of the inflammation-immune mechanism in asthma pathogenesis, suggesting that these proteins may be used in asthma diagnosis, prognosis, or therapy, and suggested biomarkers for asthma of preschool children. In conclusion, our results provide insight into the pathophysiology of asthma. We believe that the diagnostic model will facilitate clinical decision-making regarding asthma in preschool children.
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Affiliation(s)
| | | | - Haibo Lin
- Department of Pediatrics, Children’s Hospital, The Second Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang, China
| | - Yuan Sun
- Department of Pediatrics, Children’s Hospital, The Second Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang, China
| | - Lu Zhang
- Department of Pediatrics, Children’s Hospital, The Second Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang, China
| | - Feiyan Liu
- Department of Pediatrics, Children’s Hospital, The Second Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang, China
| | - Xuelin Wang
- Department of Pediatrics, Children’s Hospital, The Second Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang, China
| | - Zhihong Zhang
- Department of Pediatrics, Children’s Hospital, The Second Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang, China
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Sanders S, Barratt A, Buchbinder R, Doust J, Kazda L, Jones M, Glasziou P, Bell K. Evidence for overdiagnosis in noncancer conditions was assessed: a metaepidemiological study using the 'Fair Umpire' framework. J Clin Epidemiol 2024; 165:111215. [PMID: 37952702 DOI: 10.1016/j.jclinepi.2023.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/04/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVES To evaluate the strength of the evidence for, and the extent of, overdiagnosis in noncancer conditions. STUDY DESIGN AND SETTING We systematically searched for studies investigating overdiagnosis in noncancer conditions. Using the 'Fair Umpire' framework to assess the evidence that cases diagnosed by one diagnostic strategy but not by another may be overdiagnosed, two reviewers independently identified whether a Fair Umpire-a disease-specific clinical outcome, a test result or risk factor that can determine whether an additional case does or does not have disease-was present. Disease-specific clinical outcomes provide the strongest evidence for overdiagnosis, follow-up or concurrent tests provide weaker evidence, and risk factors provide only weak evidence. Studies without a Fair Umpire provide the weakest evidence of overdiagnosis. RESULTS Of 132 studies, 47 (36%) did not include a Fair Umpire to adjudicate additional diagnoses. When present, the most common Umpire was a single test or risk factor (32% of studies), with disease-specific clinical outcome Umpires used in only 21% of studies. Estimates of overdiagnosis included 43-45% of screen-detected acute abdominal aneurysms, 54% of cases of acute kidney injury, and 77% of cases of oligohydramnios in pregnancy. CONCLUSION Much of the current evidence for overdiagnosis in noncancer conditions is weak. Application of the framework can guide development of robust studies to detect and estimate overdiagnosis in noncancer conditions, ultimately informing evidence-based policies to reduce it.
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Affiliation(s)
- Sharon Sanders
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland 4229, Australia.
| | - Alexandra Barratt
- Sydney School of Public Health, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, New South Wales 2006, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3800, Australia
| | - Jenny Doust
- Centre for Longitudinal and Life Course Research, School of Public Health, University of Queensland, Herston, Queensland 4006, Australia
| | - Luise Kazda
- NHMRC Healthy Environments And Lives (HEAL) National Research Network, National Centre for Epidemiology and Population Health, College of Health and Medicine, The Australian National University, Canberra, Australian Capital Territory 2601, Australia
| | - Mark Jones
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland 4229, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland 4229, Australia
| | - Katy Bell
- Sydney School of Public Health, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, New South Wales 2006, Australia
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Kallis C, Maslova E, Morgan AD, Sinha I, Roberts G, van der Valk RJP, Quint JK, Tran TN. Recent trends in asthma diagnosis, preschool wheeze diagnosis and asthma exacerbations in English children and adolescents: a SABINA Jr study. Thorax 2023; 78:1175-1180. [PMID: 37524391 PMCID: PMC10715559 DOI: 10.1136/thorax-2022-219757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 06/26/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Asthma-related burden remains poorly characterised in children in the UK. We quantified recent trends in asthma prevalence and burden in a UK population-based cohort (1‒17-year-olds). METHODS The Clinical Practice Research Datalink Aurum database (2008‒2018) was used to assess annual asthma incidence and prevalence in 1‒17-year-olds and preschool wheeze in 1‒5-year-olds, stratified by sex and age. During the same period, annual asthma exacerbation rates were assessed in those with either a diagnosis of preschool wheeze or asthma. RESULTS Annual asthma incidence rates decreased by 51% from 1403.4 (95% CI 1383.7 to 1423.2) in 2008 to 688.0 (95% CI 676.3 to 699.9) per 105 person-years (PYs) in 2018, with the most pronounced decrease observed in 1‒5-year olds (decreasing by 65%, from 2556.9 (95% CI 2509.8 to 2604.7) to 892.3 (95% CI 866.9 to 918.3) per 105 PYs). The corresponding decreases for the 6‒11- and 12‒17-year-olds were 36% (1139.9 (95% CI 1110.6 to 1169.7) to 739.9 (95% CI 720.5 to 759.8)) and 20% (572.3 (95% CI 550.4 to 594.9) to 459.5 (95% CI 442.9 to 476.4)) per 105 PYs, respectively. The incidence of preschool wheeze decreased over time and was slightly more pronounced in the 1‒3 year-olds than in the 4-year-olds. Prevalence of asthma and preschool wheeze also decreased over time, from 18.0% overall in 2008 to 10.2% in 2018 for asthma. Exacerbation rates increased over time from 1.33 (95% CI 1.31 to 1.35) per 10 PYs in 2008 to 1.81 (95% CI 1.78 to 1.83) per 10 PYs in 2018. CONCLUSION Paediatric asthma incidence decreased in the UK since 2008, particularly in 1-5-year-olds; this was accompanied by a decline in asthma prevalence. Preschool wheeze incidence also decreased in this age group. However, exacerbation rates have been increasing.
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Affiliation(s)
- Constantinos Kallis
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Ann D Morgan
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Ian Sinha
- Alder Hey Children's Hospital, Liverpool, UK
- Division of Child Health, University of Liverpool, Liverpool, UK
| | - Graham Roberts
- University of Southampton Faculty of Medicine, Southampton, UK
- NIHR Southampton, Biomedical Research Centre, University Hospital Southampton, Southampton, UK
- David Hide Asthma and Allergy Centre, St Mary's Hospital, Isle of Wight, UK
| | | | - Jennifer K Quint
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Trung N Tran
- Biopharmaceuticals Medical, Respiratory and Immunology, AstraZeneca, Gaithersburg, Maryland, USA
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Daines L, Bonnett LJ, Tibble H, Boyd A, Thomas R, Price D, Turner SW, Lewis SC, Sheikh A, Pinnock H. Deriving and validating an asthma diagnosis prediction model for children and young people in primary care. Wellcome Open Res 2023; 8:195. [PMID: 37928213 PMCID: PMC10622861 DOI: 10.12688/wellcomeopenres.19078.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 11/08/2023] Open
Abstract
Introduction: Accurately diagnosing asthma can be challenging. We aimed to derive and validate a prediction model to support primary care clinicians assess the probability of an asthma diagnosis in children and young people. Methods: The derivation dataset was created from the Avon Longitudinal Study of Parents and Children (ALSPAC) linked to electronic health records. Participants with at least three inhaled corticosteroid prescriptions in 12-months and a coded asthma diagnosis were designated as having asthma. Demographics, symptoms, past medical/family history, exposures, investigations, and prescriptions were considered as candidate predictors. Potential candidate predictors were included if data were available in ≥60% of participants. Multiple imputation was used to handle remaining missing data. The prediction model was derived using logistic regression. Internal validation was completed using bootstrap re-sampling. External validation was conducted using health records from the Optimum Patient Care Research Database (OPCRD). Results: Predictors included in the final model were wheeze, cough, breathlessness, hay-fever, eczema, food allergy, social class, maternal asthma, childhood exposure to cigarette smoke, prescription of a short acting beta agonist and the past recording of lung function/reversibility testing. In the derivation dataset, which comprised 11,972 participants aged <25 years (49% female, 8% asthma), model performance as indicated by the C-statistic and calibration slope was 0.86, 95% confidence interval (CI) 0.85-0.87 and 1.00, 95% CI 0.95-1.05 respectively. In the external validation dataset, which included 2,670 participants aged <25 years (50% female, 10% asthma), the C-statistic was 0.85, 95% CI 0.83-0.88, and calibration slope 1.22, 95% CI 1.09-1.35. Conclusions: We derived and validated a prediction model for clinicians to calculate the probability of asthma diagnosis for a child or young person up to 25 years of age presenting to primary care. Following further evaluation of clinical effectiveness, the prediction model could be implemented as a decision support software.
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Affiliation(s)
- Luke Daines
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Laura J Bonnett
- Department of Biostatistics, University of Liverpool, Liverpool, L69 3GL, UK
| | - Holly Tibble
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Andy Boyd
- Institute of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - Richard Thomas
- Institute of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, 573969, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, AB25 2ZG, UK
| | - Steve W Turner
- Child Health, University of Aberdeen, Aberdeen, AB25 2ZG, UK
- Women and Children Division, NHS Grampian, Aberdeen, AB25 2ZG, UK
| | - Steff C Lewis
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, EH16 4UX, UK
| | - Aziz Sheikh
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Hilary Pinnock
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, EH8 9AG, UK
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Daines L, Bonnett LJ, Tibble H, Boyd A, Thomas R, Price D, Turner SW, Lewis SC, Sheikh A, Pinnock H. Deriving and validating an asthma diagnosis prediction model for children and young people in primary care. Wellcome Open Res 2023; 8:195. [PMID: 37928213 PMCID: PMC10622861 DOI: 10.12688/wellcomeopenres.19078.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction: Accurately diagnosing asthma can be challenging. We aimed to derive and validate a prediction model to support primary care clinicians assess the probability of an asthma diagnosis in children and young people. Methods: The derivation dataset was created from the Avon Longitudinal Study of Parents and Children (ALSPAC) linked to electronic health records. Participants with at least three inhaled corticosteroid prescriptions in 12-months and a coded asthma diagnosis were designated as having asthma. Demographics, symptoms, past medical/family history, exposures, investigations, and prescriptions were considered as candidate predictors. Potential candidate predictors were included if data were available in ≥60% of participants. Multiple imputation was used to handle remaining missing data. The prediction model was derived using logistic regression. Internal validation was completed using bootstrap re-sampling. External validation was conducted using health records from the Optimum Patient Care Research Database (OPCRD). Results: Predictors included in the final model were wheeze, cough, breathlessness, hay-fever, eczema, food allergy, social class, maternal asthma, childhood exposure to cigarette smoke, prescription of a short acting beta agonist and the past recording of lung function/reversibility testing. In the derivation dataset, which comprised 11,972 participants aged <25 years (49% female, 8% asthma), model performance as indicated by the C-statistic and calibration slope was 0.86, 95% confidence interval (CI) 0.85-0.87 and 1.00, 95% CI 0.95-1.05 respectively. In the external validation dataset, which included 2,670 participants aged <25 years (50% female, 10% asthma), the C-statistic was 0.85, 95% CI 0.83-0.88, and calibration slope 1.22, 95% CI 1.09-1.35. Conclusions: We derived and validated a prediction model for clinicians to calculate the probability of asthma diagnosis for a child or young person up to 25 years of age presenting to primary care. Following further evaluation of clinical effectiveness, the prediction model could be implemented as a decision support software.
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Affiliation(s)
- Luke Daines
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Laura J Bonnett
- Department of Biostatistics, University of Liverpool, Liverpool, L69 3GL, UK
| | - Holly Tibble
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Andy Boyd
- Institute of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - Richard Thomas
- Institute of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, 573969, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, AB25 2ZG, UK
| | - Steve W Turner
- Child Health, University of Aberdeen, Aberdeen, AB25 2ZG, UK
- Women and Children Division, NHS Grampian, Aberdeen, AB25 2ZG, UK
| | - Steff C Lewis
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, EH16 4UX, UK
| | - Aziz Sheikh
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Hilary Pinnock
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, EH8 9AG, UK
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Pinnock H, Noble M, Lo D, McClatchey K, Marsh V, Hui CY. Personalised management and supporting individuals to live with their asthma in a primary care setting. Expert Rev Respir Med 2023; 17:577-596. [PMID: 37535011 DOI: 10.1080/17476348.2023.2241357] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/24/2023] [Indexed: 08/04/2023]
Abstract
INTRODUCTION Complementing recognition of biomedical phenotypes, a primary care approach to asthma care recognizes diversity of disease, health beliefs, and lifestyle at a population and individual level. AREAS COVERED We review six aspects of personalized care particularly pertinent to primary care management of asthma: personalizing support for individuals living with asthma; targeting asthma care within populations; managing phenotypes of wheezy pre-school children; personalizing management to the individual; meeting individual preferences for provision of asthma care; optimizing digital approaches to enhance personalized care. EXPERT OPINION In a primary care setting, personalized management and supporting individuals to live with asthma extend beyond the contemporary concepts of biological phenotypes and pharmacological 'treatable traits' to encompass evidence-based tailored support for self-management, and delivery of patient-centered care including motivational interviewing. It extends to how we organize clinical practiceand the choices provided in mode of consultation. Diagnostic uncertainty due to recognition of phenotypes of pre-school wheeze remains a challenge for primary care. Digital health can support personalized management, but there are concerns about increasing inequities. This broad approach reflects the traditionally holistic ethos of primary care ('knowing their patients and understanding their communities'), but the core concepts resonate with all healthcare.
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Affiliation(s)
- Hilary Pinnock
- Usher Institute, The University of Edinburgh, Edinburgh, UK
- Whitstable Medical Practice, Whitstable, Kent, UK
| | - Mike Noble
- Primary Care Research Group, Institute of Health Research, University of Exeter Medical School, Exeter, UK
- Acle Medical Centre, Norfolk, UK
| | - David Lo
- Department of Respiratory Sciences, College of Life Sciences, NIHR Biomedical Research Centre (Respiratory Theme), University of Leicester, Leicester, UK
- Department of Paediatric Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Viv Marsh
- Usher Institute, The University of Edinburgh, Edinburgh, UK
- CYP Asthma Transformation Black Country Integrated Care Board, Wolverhampton, UK
| | - Chi Yan Hui
- Usher Institute, The University of Edinburgh, Edinburgh, UK
- Deanery of Molecular, Genetic and Population Health Sciences, The University of Edinburgh, Edinburgh, UK
- The UK Engineering Council, London, UK
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Scotney E, Fleming L, Saglani S, Sonnappa S, Bush A. Advances in the pathogenesis and personalised treatment of paediatric asthma. BMJ MEDICINE 2023; 2:e000367. [PMID: 37841968 PMCID: PMC10568124 DOI: 10.1136/bmjmed-2022-000367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 05/05/2023] [Indexed: 10/17/2023]
Abstract
The diversity of pathology of severe paediatric asthma demonstrates that the one-size-fits-all approach characterising many guidelines is inappropriate. The term "asthma" is best used to describe a clinical syndrome of wheeze, chest tightness, breathlessness, and sometimes cough, making no assumptions about underlying pathology. Before personalising treatment, it is essential to make the diagnosis correctly and optimise basic management. Clinicians must determine exactly what type of asthma each child has. We are moving from describing symptom patterns in preschool wheeze to describing multiple underlying phenotypes with implications for targeting treatment. Many new treatment options are available for school age asthma, including biological medicines targeting type 2 inflammation, but a paucity of options are available for non-type 2 disease. The traditional reliever treatment, shortacting β2 agonists, is being replaced by combination inhalers containing inhaled corticosteroids and fast, longacting β2 agonists to treat the underlying inflammation in even mild asthma and reduce the risk of asthma attacks. However, much decision making is still based on adult data extrapolated to children. Better inclusion of children in future research studies is essential, if children are to benefit from these new advances in asthma treatment.
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Affiliation(s)
- Elizabeth Scotney
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Samatha Sonnappa
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Andrew Bush
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
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11
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Granell R, Curtin JA, Haider S, Kitaba NT, Mathie SA, Gregory LG, Yates LL, Tutino M, Hankinson J, Perretti M, Vonk JM, Arshad HS, Cullinan P, Fontanella S, Roberts GC, Koppelman GH, Simpson A, Turner SW, Murray CS, Lloyd CM, Holloway JW, Custovic A. A meta-analysis of genome-wide association studies of childhood wheezing phenotypes identifies ANXA1 as a susceptibility locus for persistent wheezing. eLife 2023; 12:e84315. [PMID: 37227431 PMCID: PMC10292845 DOI: 10.7554/elife.84315] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 05/22/2023] [Indexed: 05/26/2023] Open
Abstract
Background Many genes associated with asthma explain only a fraction of its heritability. Most genome-wide association studies (GWASs) used a broad definition of 'doctor-diagnosed asthma', thereby diluting genetic signals by not considering asthma heterogeneity. The objective of our study was to identify genetic associates of childhood wheezing phenotypes. Methods We conducted a novel multivariate GWAS meta-analysis of wheezing phenotypes jointly derived using unbiased analysis of data collected from birth to 18 years in 9568 individuals from five UK birth cohorts. Results Forty-four independent SNPs were associated with early-onset persistent, 25 with pre-school remitting, 33 with mid-childhood remitting, and 32 with late-onset wheeze. We identified a novel locus on chr9q21.13 (close to annexin 1 [ANXA1], p<6.7 × 10-9), associated exclusively with early-onset persistent wheeze. We identified rs75260654 as the most likely causative single nucleotide polymorphism (SNP) using Promoter Capture Hi-C loops, and then showed that the risk allele (T) confers a reduction in ANXA1 expression. Finally, in a murine model of house dust mite (HDM)-induced allergic airway disease, we demonstrated that anxa1 protein expression increased and anxa1 mRNA was significantly induced in lung tissue following HDM exposure. Using anxa1-/- deficient mice, we showed that loss of anxa1 results in heightened airway hyperreactivity and Th2 inflammation upon allergen challenge. Conclusions Targeting this pathway in persistent disease may represent an exciting therapeutic prospect. Funding UK Medical Research Council Programme Grant MR/S025340/1 and the Wellcome Trust Strategic Award (108818/15/Z) provided most of the funding for this study.
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Affiliation(s)
- Raquel Granell
- MRC Integrative Epidemiology Unit, Department of Population Health Sciences, Bristol Medical School, University of BristolBristolUnited Kingdom
| | - John A Curtin
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, and Manchester University NHS Foundation TrustManchesterUnited Kingdom
| | - Sadia Haider
- National Heart and Lung Institute, Imperial College LondonLondonUnited Kingdom
| | - Negusse Tadesse Kitaba
- Human Development and Health, Faculty of Medicine, University of SouthamptonSouthamptonUnited Kingdom
| | - Sara A Mathie
- National Heart and Lung Institute, Imperial College LondonLondonUnited Kingdom
| | - Lisa G Gregory
- National Heart and Lung Institute, Imperial College LondonLondonUnited Kingdom
| | - Laura L Yates
- National Heart and Lung Institute, Imperial College LondonLondonUnited Kingdom
| | - Mauro Tutino
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, and Manchester University NHS Foundation TrustManchesterUnited Kingdom
| | - Jenny Hankinson
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, and Manchester University NHS Foundation TrustManchesterUnited Kingdom
| | - Mauro Perretti
- William Harvey Research Institute, Barts and The London School of Medicine Queen Mary University of LondonLondonUnited Kingdom
| | - Judith M Vonk
- Department of Epidemiology, University of Groningen, University Medical Center Groningen\GroningenNetherlands
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (GRIAC)GroningenNetherlands
| | - Hasan S Arshad
- NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation TrustSouthamptonUnited Kingdom
- David Hide Asthma and Allergy Research CentreIsle of WightUnited Kingdom
- Clinical and Experimental Sciences, Faculty of Medicine, University of SouthamptonSouthamptonUnited Kingdom
| | - Paul Cullinan
- National Heart and Lung Institute, Imperial College LondonLondonUnited Kingdom
| | - Sara Fontanella
- National Heart and Lung Institute, Imperial College LondonLondonUnited Kingdom
| | - Graham C Roberts
- Human Development and Health, Faculty of Medicine, University of SouthamptonSouthamptonUnited Kingdom
- NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation TrustSouthamptonUnited Kingdom
- David Hide Asthma and Allergy Research CentreIsle of WightUnited Kingdom
| | - Gerard H Koppelman
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (GRIAC)GroningenNetherlands
- Department of Pediatric Pulmonology and Pediatric Allergology, University of Groningen, University Medical Center Groningen, Beatrix Children’s HospitalGroningenNetherlands
| | - Angela Simpson
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, and Manchester University NHS Foundation TrustManchesterUnited Kingdom
| | - Steve W Turner
- Child Health, University of AberdeenAberdeenUnited Kingdom
| | - Clare S Murray
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, and Manchester University NHS Foundation TrustManchesterUnited Kingdom
| | - Clare M Lloyd
- National Heart and Lung Institute, Imperial College LondonLondonUnited Kingdom
| | - John W Holloway
- Human Development and Health, Faculty of Medicine, University of SouthamptonSouthamptonUnited Kingdom
- NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation TrustSouthamptonUnited Kingdom
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College LondonLondonUnited Kingdom
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12
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Linares MB, Rodríguez MA, Icarte DM, Martínez BA, Milla VP, Zygier NF, Olmos CR. Bronchodilator Response in FEF 25-75 for the Diagnosis of Asthma in Children. Respir Care 2023; 68:505-510. [PMID: 36963964 PMCID: PMC10173107 DOI: 10.4187/respcare.10177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Abstract
BACKGROUND Spirometry tests with a bronchodilator response (BDR) in FEV1, a methacholine concentration that produces a 20% drop in FEV1 (PC20) ≤ 2 mg/mL, and a positive exercise test have high specificity for the diagnosis of asthma in children. However, the value of forced expiratory flow during the middle half of the FVC maneuver (FEF25-75) in spirometry has been questioned. The objective of this study was to relate the BDR in FEF25-75 of spirometry tests with normal FEV1 and FEV1/FVC to airway hyper-responsiveness (AHR) to methacholine or exercise in children age 5-15 y with clinical suspicion of asthma. METHODS This was a cross-sectional study of spirometry tests performed between January 2017-December 2019 in children age 5-15 y with diagnostic suspicion of asthma who had a methacholine and/or exercise testing within a period not exceeding 60 d between exams. RESULTS The mean (± SD) age of the children was 9.04 ± 2.67 y, with a range of 5-15 y, and 56.17% were male. Of the 324 spirometry tests with normal FEV1 and FEV1/FVC, 66 (20.4%) tests showed BDR in FEF25-75. A total of 46.9% and 33.3% of the children with and without BDR in FEF25-75, respectively, had a PC20 value ≤ 2 mg/mL and/or a positive exercise testing (P = .039). CONCLUSIONS Children with suspected asthma and normal spirometry, other than BDR in FEF25-75, had greater AHR than those without BDR in FEF25-75. BDR in FEF25-75 was not always accompanied by AHR to confirm the diagnosis of asthma, so this study suggests that assessment of FEF25-75 alone is not always reliable for ruling in or ruling out AHR in the setting of otherwise normal spirometry results in children with suspected asthma.
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Affiliation(s)
| | | | - Danae M Icarte
- Centro de Salud Familiar El Belloto, Servicio de Salud Viña del Mar, Quillota, Valparaíso, Chile
| | - Bitter A Martínez
- Centro de Salud Familiar El Belloto SUR, Servicio de Salud Valparaíso, Valparaíso, Chile; and Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Valentina P Milla
- Centro de Salud Familiar El Belloto SUR, Servicio de Salud Valparaíso, Valparaíso, Chile; and Universidad Finis Terrae, Santiago, Chile
| | - Noelia F Zygier
- Escuela de Medicina, Universidad Andrés Bello; Research Unit, Clínica INDISA, Santiago, Chile
| | - Claudio R Olmos
- Escuela de Medicina, Universidad Andre's Bello; Research Unit, Cliínica INDISA, Santiago, Chile
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13
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Weber R, Streckenbach B, Welti L, Inci D, Kohler M, Perkins N, Zenobi R, Micic S, Moeller A. Online breath analysis with SESI/HRMS for metabolic signatures in children with allergic asthma. Front Mol Biosci 2023; 10:1154536. [PMID: 37065443 PMCID: PMC10102578 DOI: 10.3389/fmolb.2023.1154536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/16/2023] [Indexed: 04/03/2023] Open
Abstract
Introduction: There is a need to improve the diagnosis and management of pediatric asthma. Breath analysis aims to address this by non-invasively assessing altered metabolism and disease-associated processes. Our goal was to identify exhaled metabolic signatures that distinguish children with allergic asthma from healthy controls using secondary electrospray ionization high-resolution mass spectrometry (SESI/HRMS) in a cross-sectional observational study.Methods: Breath analysis was performed with SESI/HRMS. Significant differentially expressed mass-to-charge features in breath were extracted using the empirical Bayes moderated t-statistics test. Corresponding molecules were putatively annotated by tandem mass spectrometry database matching and pathway analysis.Results: 48 allergic asthmatics and 56 healthy controls were included in the study. Among 375 significant mass-to-charge features, 134 were putatively identified. Many of these could be grouped to metabolites of common pathways or chemical families. We found several pathways that are well-represented by the significant metabolites, for example, lysine degradation elevated and two arginine pathways downregulated in the asthmatic group. Assessing the ability of breath profiles to classify samples as asthmatic or healthy with supervised machine learning in a 10 times repeated 10-fold cross-validation revealed an area under the receiver operating characteristic curve of 0.83.Discussion: For the first time, a large number of breath-derived metabolites that discriminate children with allergic asthma from healthy controls were identified by online breath analysis. Many are linked to well-described metabolic pathways and chemical families involved in pathophysiological processes of asthma. Furthermore, a subset of these volatile organic compounds showed high potential for clinical diagnostic applications.
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Affiliation(s)
- Ronja Weber
- Department of Respiratory Medicine, University Children's Hospital Zurich, Zurich, Switzerland
| | - Bettina Streckenbach
- Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
| | - Lara Welti
- Department of Respiratory Medicine, University Children's Hospital Zurich, Zurich, Switzerland
| | - Demet Inci
- Department of Respiratory Medicine, University Children's Hospital Zurich, Zurich, Switzerland
| | - Malcolm Kohler
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Nathan Perkins
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital Zurich, Zurich, Switzerland
| | - Renato Zenobi
- Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
| | - Srdjan Micic
- Department of Respiratory Medicine, University Children's Hospital Zurich, Zurich, Switzerland
| | - Alexander Moeller
- Department of Respiratory Medicine, University Children's Hospital Zurich, Zurich, Switzerland
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14
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Pediatric obesity and severe asthma: Targeting pathways driving inflammation. Pharmacol Res 2023; 188:106658. [PMID: 36642111 DOI: 10.1016/j.phrs.2023.106658] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 01/04/2023] [Accepted: 01/10/2023] [Indexed: 01/13/2023]
Abstract
Asthma affects more than 300 million people of all ages worldwide, including about 10-15% of school-aged children, and its prevalence is increasing. Severe asthma (SA) is a particular and rare phenotype requiring treatment with high-dose inhaled corticosteroids plus a second controller and/or systemic glucocorticoid courses to achieve symptom control or remaining "uncontrolled" despite this therapy. In SA, other diagnoses have been excluded, and potential exacerbating factors have been addressed. Notably, obese asthmatics are at higher risk of developing SA. Obesity is both a major risk factor and a disease modifier of asthma in children and adults: two main "obese asthma" phenotypes have been described in childhood with high or low levels of Type 2 inflammation biomarkers, respectively, the former characterized by early onset and eosinophilic inflammation and the latter by neutrophilic inflammation and late-onset. Nevertheless, the interplay between obesity and asthma is far more complex and includes obese tissue-driven inflammatory pathways, mechanical factors, comorbidities, and poor response to corticosteroids. This review outlines the most recent findings on SA in obese children, particularly focusing on inflammatory pathways, which are becoming of pivotal importance in order to identify selective targets for specific treatments, such as biological agents.
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15
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Canny A, Donaghy E, Murray V, Campbell L, Stonham C, Bush A, McKinstry B, Milne H, Pinnock H, Daines L. Patient views on asthma diagnosis and how a clinical decision support system could help: A qualitative study. Health Expect 2022; 26:307-317. [PMID: 36370457 PMCID: PMC9854294 DOI: 10.1111/hex.13657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/22/2022] [Accepted: 10/23/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Making a diagnosis of asthma can be challenging for clinicians and patients. A clinical decision support system (CDSS) for use in primary care including a patient-facing mode, could change how information is shared between patients and healthcare professionals and improve the diagnostic process. METHODS Participants diagnosed with asthma within the last 5 years were recruited from general practices across four UK regions. In-depth interviews were used to explore patient experiences relating to their asthma diagnosis and to understand how a CDSS could be used to improve the diagnostic process for patients. Interviews were audio recorded, transcribed verbatim and analysed using a thematic approach. RESULTS Seventeen participants (12 female) undertook interviews, including 14 individuals and 3 parents of children with asthma. Being diagnosed with asthma was generally considered an uncertain process. Participants felt a lack of consultation time and poor communication affected their understanding of asthma and what to expect. Had the nature of asthma and the steps required to make a diagnosis been explained more clearly, patients felt their understanding and engagement in asthma self-management could have been improved. Participants considered that a CDSS could provide resources to support the diagnostic process, prompt dialogue, aid understanding and support shared decision-making. CONCLUSION Undergoing an asthma diagnosis was uncertain for patients if their ideas and concerns were not addressed by clinicians and were influenced by a lack of consultation time and limitations in communication. An asthma diagnosis CDSS could provide structure and an interface to prompt dialogue, provide visuals about asthma to aid understanding and encourage patient involvement. PATIENT AND PUBLIC CONTRIBUTION Prespecified semistructured interview topic guides (young person and adult versions) were developed by the research team and piloted with members of the Asthma UK Centre for Applied Research Patient and Public Involvement (PPI) group. Findings were regularly discussed within the research group and with PPI colleagues to aid the interpretation of data.
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Affiliation(s)
- Anne Canny
- Asthma UK Centre for Applied Research, Usher InstituteUniversity of EdinburghEdinburghUK
| | - Eddie Donaghy
- Asthma UK Centre for Applied Research, Usher InstituteUniversity of EdinburghEdinburghUK
| | - Victoria Murray
- Asthma UK Centre for Applied Research, Usher InstituteUniversity of EdinburghEdinburghUK
| | - Leo Campbell
- Asthma UK Centre for Applied Research, Usher InstituteUniversity of EdinburghEdinburghUK
| | - Carol Stonham
- NHS Gloucestershire Clinical Commissioning GroupGloucesterUK,Primary Care Respiratory Society (PCRS)KnowleUK
| | - Andrew Bush
- Imperial Centre for Paediatrics and Child Health and National Heart and Lung InstituteImperial CollegeLondonUK,Department of Paediatric Respiratory MedicineRoyal Brompton HospitalLondonUK
| | - Brian McKinstry
- Centre for Population and Health Sciences, Usher InstituteUniversity of EdinburghEdinburghUK
| | - Heather Milne
- South East GP UnitNHS Education for ScotlandEdinburghUK
| | - Hilary Pinnock
- Asthma UK Centre for Applied Research, Usher InstituteUniversity of EdinburghEdinburghUK
| | - Luke Daines
- Asthma UK Centre for Applied Research, Usher InstituteUniversity of EdinburghEdinburghUK
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16
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Devani P, Lo DKH, Gaillard EA. Practical approaches to the diagnosis of asthma in school-age children. Expert Rev Respir Med 2022; 16:973-981. [PMID: 36125212 DOI: 10.1080/17476348.2022.2126355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Asthma is a chronic airways disease characterized by episodes of wheeze, chest tightness, and evidence of reversible airflow obstruction. Symptoms are frequently triggered by exercise, exposure to aeroallergens, and respiratory viruses. It is the commonest non-communicable respiratory condition in children, affecting over 5.5 million children in the European Union alone. Both over- and under- diagnosis of asthma are common for several reasons. AREAS COVERED The diagnosis is frequently based on parental or patient reported non-specific symptoms alone. All major asthma guidelines now recommend the use of objective tests, including spirometry, bronchodilator reversibility testing, fraction of exhaled nitric oxide measurements and challenge testing to confirm the diagnosis. Recently, the European Respiratory Society published the first evidence-based international guidelines for diagnosing asthma in school-age children using objective measures. Major barriers to implementation in primary care and less well-resourced healthcare settings are access to relevant objective tests for children and quality assurance to obtain reliable results. EXPERT OPINION We highlight the importance of diagnosing asthma in school-age children using objective tests and outline a practical approach for the use of widely available tests. We also review challenges and barriers to implementation of objective testing in children managed outside specialist settings.
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Affiliation(s)
- Pooja Devani
- Department of Paediatric Respiratory Medicine. Leicester Children's Hospital, University Hospitals Leicester, Leicester, UK
| | - David K H Lo
- Department of Paediatric Respiratory Medicine. Leicester Children's Hospital, University Hospitals Leicester, Leicester, UK.,Department of Respiratory Sciences. Leicester NIHR Biomedical Research Centre (Respiratory Theme), University of Leicester, Leicester, UK
| | - Erol A Gaillard
- Department of Paediatric Respiratory Medicine. Leicester Children's Hospital, University Hospitals Leicester, Leicester, UK.,Department of Respiratory Sciences. Leicester NIHR Biomedical Research Centre (Respiratory Theme), University of Leicester, Leicester, UK
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17
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Al Busaidi N, Alweqayyan A, Al Zaabi A, Mahboub B, Al-Huraish F, Hameed M, Al-Ahmad M, Khadadah M, Al Lawati N, Behbehani N, Al Jabri O, Salman R, Al Mubaihsi S, Al Raisi S. Gulf Asthma Diagnosis and Management in Adults: Expert Review and Recommendations. Open Respir Med J 2022. [DOI: 10.2174/18743064-v16-e2205230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The prevalence and incidence of asthma are increasing globally because of genetic and environmental influences. Prevalence of asthma in the Gulf has been reported to range from 4.7% to 32.0% and has a substantial economic burden. In this paper, we summarize current asthma management guidance for adults, present insights, and recommendations by key opinion leaders (KOLs) in the Gulf region, and key performance indicators for guiding clinical practice for asthma diagnosis, management, and treatment in the Gulf. While it is recommended that the Global Initiative for Asthma (GINA) guidelines should be followed wherever possible for the management of asthma, KOLs in the Gulf region have presented additional recommendations based on regional challenges and insights. There is a need for better diagnosis using objective testing, increased efforts in tackling the burden of comorbidities in the region, and greater provision of the necessary tools for phenotyping severe asthma. Furthermore, there is a need for greater education for physicians regarding asthma treatment, including the importance of inhaled-corticosteroid-containing controller medication. Regionally, there is also a need for specialist asthma clinics and asthma educators, which would serve to educate physicians and their patients as well as to improve the management of patients. Finally, the use of asthma registries, digital devices, and electronic templates would be of benefit in the management of asthma patients in the region.
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18
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Chan A, De Simoni A, Wileman V, Holliday L, Newby CJ, Chisari C, Ali S, Zhu N, Padakanti P, Pinprachanan V, Ting V, Griffiths CJ. Digital interventions to improve adherence to maintenance medication in asthma. Cochrane Database Syst Rev 2022; 6:CD013030. [PMID: 35691614 PMCID: PMC9188849 DOI: 10.1002/14651858.cd013030.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Asthma is the most common chronic lung condition worldwide, affecting 334 million adults and children globally. Despite the availability of effective treatment, such as inhaled corticosteroids (ICS), adherence to maintenance medication remains suboptimal. Poor ICS adherence leads to increased asthma symptoms, exacerbations, hospitalisations, and healthcare utilisation. Importantly, suboptimal use of asthma medication is a key contributor to asthma deaths. The impact of digital interventions on adherence and asthma outcomes is unknown. OBJECTIVES To determine the effectiveness of digital interventions for improving adherence to maintenance treatments in asthma. SEARCH METHODS We identified trials from the Cochrane Airways Trials Register, which contains studies identified through multiple electronic searches and handsearches of other sources. We also searched trial registries and reference lists of primary studies. We conducted the most recent searches on 1 June 2020, with no restrictions on language of publication. A further search was run in October 2021, but studies were not fully incorporated. SELECTION CRITERIA We included randomised controlled trials (RCTs) including cluster- and quasi-randomised trials of any duration in any setting, comparing a digital adherence intervention with a non-digital adherence intervention or usual care. We included adults and children with a clinical diagnosis of asthma, receiving maintenance treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures for data collection. We used GRADE to assess quantitative outcomes where data were available. MAIN RESULTS We included 40 parallel randomised controlled trials (RCTs) involving adults and children with asthma (n = 15,207), of which eight are ongoing studies. Of the included studies, 30 contributed data to at least one meta-analysis. The total number of participants ranged from 18 to 8517 (median 339). Intervention length ranged from two to 104 weeks. Most studies (n = 29) reported adherence to maintenance medication as their primary outcome; other outcomes such as asthma control and quality of life were also commonly reported. Studies had low or unclear risk of selection bias but high risk of performance and detection biases due to inability to blind the participants, personnel, or outcome assessors. A quarter of the studies had high risk of attrition bias and selective outcome reporting. We examined the effect of digital interventions using meta-analysis for the following outcomes: adherence (16 studies); asthma control (16 studies); asthma exacerbations (six studies); unscheduled healthcare utilisation (four studies); lung function (seven studies); and quality of life (10 studies). Pooled results showed that patients receiving digital interventions may have increased adherence (mean difference of 14.66 percentage points, 95% confidence interval (CI) 7.74 to 21.57; low-certainty evidence); this is likely to be clinically significant in those with poor baseline medication adherence. Subgroup analysis by type of intervention was significant (P = 0.001), with better adherence shown with electronic monitoring devices (EMDs) (23 percentage points over control, 95% CI 10.84 to 34.16; seven studies), and with short message services (SMS) (12 percentage points over control, 95% CI 6.22 to 18.03; four studies). No significant subgroup differences were seen for interventions having an in-person component versus fully digital interventions, adherence feedback, one or multiple digital components to the intervention, or participant age. Digital interventions were likely to improve asthma control (standardised mean difference (SMD) 0.31 higher, 95% CI 0.17 to 0.44; moderate-certainty evidence) - a small but likely clinically significant effect. They may reduce asthma exacerbations (risk ratio 0.53, 95% CI 0.32 to 0.91; low-certainty evidence). Digital interventions may result in a slight change in unscheduled healthcare utilisation, although some studies reported no or a worsened effect. School or work absence data could not be included for meta-analysis due to the heterogeneity in reporting and the low number of studies. They may result in little or no difference in lung function (forced expiratory volume in one second (FEV1)): there was an improvement of 3.58% predicted FEV1, 95% CI 1.00% to 6.17%; moderate-certainty evidence); however, this is unlikely to be clinically significant as the FEV1 change is below 12%. Digital interventions likely increase quality of life (SMD 0.26 higher, 95% CI 0.07 to 0.45; moderate-certainty evidence); however, this is a small effect that may not be clinically significant. Acceptability data showed positive attitudes towards digital interventions. There were no data on cost-effectiveness or adverse events. Our confidence in the evidence was reduced by risk of bias and inconsistency. AUTHORS' CONCLUSIONS Overall, digital interventions may result in a large increase in adherence (low-certainty evidence). There is moderate-certainty evidence that digital adherence interventions likely improve asthma control to a degree that is clinically significant, and likely increase quality of life, but there is little or no improvement in lung function. The review found low-certainty evidence that digital interventions may reduce asthma exacerbations. Subgroup analyses show that EMDs may improve adherence by 23% and SMS interventions by 12%, and interventions with an in-person element and adherence feedback may have greater benefits for asthma control and adherence, respectively. Future studies should include percentage adherence as a routine outcome measure to enable comparison between studies and meta-analysis, and use validated questionnaires to assess adherence and outcomes.
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Affiliation(s)
- Amy Chan
- Centre for Behavioural Medicine, Department of Practice and Policy, UCL School of Pharmacy, University College London, London, UK
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
- Asthma UK Centre for Applied Research, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Anna De Simoni
- Wolfson Institute of Population Health, Centre for Primary Care Asthma UK Centre for Applied Research, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Vari Wileman
- Centre for Behavioural Medicine, Department of Practice and Policy, UCL School of Pharmacy, University College London, London, UK
| | - Lois Holliday
- Wolfson Institute of Population Health, Centre for Primary Care Asthma UK Centre for Applied Research, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Chris J Newby
- Research Design Service, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Claudia Chisari
- Centre for Behavioural Medicine, Department of Practice and Policy, UCL School of Pharmacy, University College London, London, UK
| | - Sana Ali
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Natalee Zhu
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
| | | | | | - Victoria Ting
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
| | - Chris J Griffiths
- Asthma UK Centre for Applied Research, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Aarestrup LK, Hermansen MN, Prahl J, Hansen KS, Chawes BL. Objective confirmation of asthma diagnosis, treatment adherence and patient outcomes in children and adolescents. Acta Paediatr 2022; 111:1220-1229. [PMID: 34905254 DOI: 10.1111/apa.16216] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 02/06/2023]
Abstract
AIM The aim of this study was to investigate the diagnostic workup in children with asthma hypothesising that objective confirmation of the diagnosis is associated with improved treatment adherence and patient outcomes. METHODS We reviewed medical records of children aged 5-18 years diagnosed with asthma at the Department of Paediatric and Adolescent Medicine, Herlev-Gentofte Hospital, Denmark, in 2018. Objective confirmation of the diagnosis was based on either (1) lung function, (2) bronchodilator response, (3) bronchial hyperresponsiveness and/or (4) elevated FeNO and was associated with treatment adherence (proportion of days covered, PDC), lung function development and exacerbations during a two-year follow-up period. RESULTS A total of 88 children were included. Asthma was objectively confirmed in 67 (76%). Children with objective confirmation of the diagnosis were more likely to redeem short-acting beta-2-agonist prescriptions: at least once, aOR = 1.3 (95% CI, 1.1-13.1), p = 0.036, and were more adherent to inhaled corticosteroid treatment: PDC>80%, aOR = 10.4 (1.8-201.1), p = 0.033. Further, objective confirmation was associated with improved lung function and reduced bronchodilator response, but not with exacerbations. CONCLUSION Objective confirmation of the asthma diagnosis in children is associated with an increased treatment adherence and improved lung function, which underlines the importance of conducting objective tests in the diagnostic workup in paediatric asthma management.
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Affiliation(s)
- Louise K. Aarestrup
- Department of Paediatric and Adolescent Medicine Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
| | - Mette N. Hermansen
- Department of Paediatric and Adolescent Medicine Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
| | - Julie Prahl
- Department of Paediatric and Adolescent Medicine Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
| | - Kirsten S. Hansen
- Department of Paediatric and Adolescent Medicine Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
- Allergy Clinic Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
| | - Bo L. Chawes
- Department of Paediatric and Adolescent Medicine Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
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20
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Pearce CJ, Chan AHY, Jackson T, Fleming L, Foot H, Bush A, Horne R. Features of successful interventions to improve adherence to inhaled corticosteroids in children with asthma: A narrative systematic review. Pediatr Pulmonol 2022; 57:822-847. [PMID: 35064651 PMCID: PMC9303909 DOI: 10.1002/ppul.25838] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/10/2022] [Accepted: 01/18/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Nonadherence to inhaled corticosteroids (ICSs) in children with asthma leads to significant morbidity and mortality. Few adherence interventions have been effective and little is known about what contributes to intervention effectiveness. This systematic review summarizes the efficacy and the characteristics of effective interventions. METHODS Six databases were systematically searched on October 3, 2020 for randomized control trials measuring adherence to ICS in children with asthma. A narrative synthesis was conducted focusing on intervention efficacy and study reliability. Intervention content was coded based on the National Institute for Health and Care Excellence guidelines for medicines adherence (the Perceptions and Practicalities Approach, PAPA) and behavior change techniques (BCTs), to determine the effective aspects of the intervention. RESULTS Of 240 studies identified, 25 were eligible for inclusion. Thirteen of the 25 studies were categorized as being highly reliable. Nine of the 13 interventions were effective at increasing adherence and 6 of those met the criteria for a PAPA intervention. Techniques targeting perceptions and practicalities in successful interventions included rewards, reminders, feedback and monitoring of adherence, pharmacological support, instruction on how to take their ICS/adhere, and information about triggers for symptoms and nonadherence. CONCLUSION Adherence interventions in children with asthma have mixed effectiveness. Effective intervention studies were more frequently of higher quality, were tailored to individuals' perceptual and practical adherence barriers, and used multiple BCTs. However, due to the small number of included studies and varying study design quality, conclusions drawn here are preliminary. Future research is needed to test a PAPA-based intervention with a rigorous study design.
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Affiliation(s)
- Christina J Pearce
- Department of Practice and Policy, School of Pharmacy, University College London, London, UK.,Usher Institute, Asthma UK Centre for Applied Research, London, UK
| | - Amy H Y Chan
- Department of Practice and Policy, School of Pharmacy, University College London, London, UK.,Usher Institute, Asthma UK Centre for Applied Research, London, UK.,Faculty of Medical and Health Sciences, School of Pharmacy, The University of Auckland, Auckland, New Zealand
| | - Tracy Jackson
- Usher Institute, Asthma UK Centre for Applied Research, London, UK
| | - Louise Fleming
- Usher Institute, Asthma UK Centre for Applied Research, London, UK.,Pediatric Respiratory Medicine, Royal Brompton Hospital, London, UK.,Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Holly Foot
- Faculty of Medical and Health Sciences, School of Pharmacy, The University of Auckland, Auckland, New Zealand
| | - Andy Bush
- Usher Institute, Asthma UK Centre for Applied Research, London, UK.,Pediatric Respiratory Medicine, Royal Brompton Hospital, London, UK.,Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Rob Horne
- Department of Practice and Policy, School of Pharmacy, University College London, London, UK.,Usher Institute, Asthma UK Centre for Applied Research, London, UK
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21
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Hammer IJ, Halvorsen T, Vollsaeter M, Hilland M, Heimdal JH, Røksund OD, Clemm HH. Conundrums in the breathless athlete; exercise induced laryngeal obstruction or asthma? Scand J Med Sci Sports 2022; 32:1041-1049. [PMID: 35114031 PMCID: PMC9303344 DOI: 10.1111/sms.14137] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/30/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE Exercise-induced bronchoconstriction (EIB) and exercise-induced laryngeal obstruction (EILO) are two disorders commonly considered when athletes complain of exertional dyspnea. They are highly different but often confused. We aimed to address this diagnostic challenge and its consequences in elite athletes. METHODS We included all athletes competing at national or international level, referred to our institution for workup for EILO during 2013-2016. We diagnosed EILO from video-recorded laryngoscopy performed during maximal cardiopulmonary treadmill exercise (CLE-test). Symptoms and previous diagnostic evaluations were obtained from referral letters and chart reviews. RESULTS EILO was diagnosed in 73/101 referred athletes, of whom 70/73 had moderate/severe supraglottic obstruction and 3/73 had primarily glottic obstruction with only minor supraglottic involvement. Of the 73 athletes with EILO, we were able to identify objective tests for asthma in 55 participants, of whom 22 had findings supporting asthma. However, 58/73 had used asthma therapy at some time previously, with current use in 28. Only three reported that asthma medication had improved their exercise related breathing problems, two of whom with tests confirming asthma. Treatment for EILO improved breathing problems in all but four. CONCLUSIONS Objective testing verified EILO in most of the referred athletes. EILO coexisting with asthma was common, and large proportions had used asthma medication; however, few reported effect on exercise related breathing problems. Unexplained persistent exertional dyspnoea must not lead to indiscriminate escalation of asthma treatment, but instead incite investigation for EILO, either as a co-morbidity or as a differential diagnosis.
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Affiliation(s)
- Ida Jansrud Hammer
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Thomas Halvorsen
- Norwegian School of Sports Sciences, Oslo, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Maria Vollsaeter
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Magnus Hilland
- Department of Otolaryngology/Head and Neck surgery, Haukeland University Hospital, Bergen, Norway
| | - John-Helge Heimdal
- Department of Otolaryngology/Head and Neck surgery, Haukeland University Hospital, Bergen, Norway.,Department of Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ola Drange Røksund
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Otolaryngology/Head and Neck surgery, Haukeland University Hospital, Bergen, Norway.,The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Hege Havstad Clemm
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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22
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Sunde RB, Thorsen J, Pedersen CET, Stokholm J, Bønnelykke K, Chawes B, Bisgaard H. Prenatal tobacco exposure and risk of asthma and allergy outcomes in childhood. Eur Respir J 2022; 59:2100453. [PMID: 34244319 DOI: 10.1183/13993003.00453-2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/21/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Harmful effects of prenatal tobacco exposure and possible interaction with 17q12-21 genetic variants have been shown for some asthma outcomes in childhood, whereas findings related to allergy outcomes are more inconsistent. This study aimed to examine the effect of prenatal tobacco exposure and relation to 17q12-21 genotype on a wide array of asthma and allergy-related outcomes in early childhood. METHODS Prenatal tobacco exposure was determined by maternal smoking during the third trimester (yes/no) in 411 children from the phenotyped Copenhagen Prospective Studies on Asthma in Childhood 2000 (COPSAC2000) birth cohort with clinical follow-up to age 7 years. The rs7216389 single nucleotide polymorphism was used as main representative of the 17q12-21 locus. Asthma end-points included asthma diagnosis, exacerbations, episodes with troublesome lung symptoms and lower respiratory tract infections, spirometry, plethysmography, bronchial responsiveness to methacholine, exercise and cold dry air. Allergy-related endpoints included aeroallergen sensitisation, allergic rhinitis, fractional exhaled nitric oxide, blood eosinophil count and urine eosinophil protein X levels. Statistical analyses were done using Cox regression, linear regression, logistic regression and quasi-Poisson regression. RESULTS Prenatal tobacco exposure increased the risk of asthma (adjusted hazard ratio (aHR) 2.05, 95% CI 1.13-3.73; p=0.02), exacerbations (aHR 3.76, 95% CI 2.05-6.91; p<0.001), number of LRTIs (adjusted incidence rate ratio 1.87, 95% CI 1.34-2.55; p<0.001), and was associated with decreased spirometry indices (forced expiratory volume in 1 s (FEV1) adjusted mean difference (aMD) -0.07 L, 95% CI -0.13- -0.005 L, p=0.03; maximal mid-expiratory flow aMD -0.19 L·s-1, -0.34- -0.04 L·s-1, p=0.01) and increased bronchial responsiveness to methacholine (provocative dose of methacholine causing a 20% drop in FEV1 adjusted geometric mean ratio 0.55, 95% CI 0.31-0.96; p=0.04). In contrast, there was no association with any allergy-related end-points. The effect on asthma depended on 17q12-21 genotype with an increased risk only among children without risk alleles. CONCLUSION Prenatal tobacco exposure was associated with asthma dependent on 17q12-21 genotype and with exacerbations, lung function and bronchial responsiveness, but not with any allergy-related outcomes. This suggests that tobacco exposure in utero leads to adverse lung developmental/structural effects rather than susceptibility to develop allergy and type 2 inflammation.
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Affiliation(s)
- Rikke Bjersand Sunde
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Dept of Pediatrics, Slagelse Sygehus, Slagelse, Denmark
| | - Jonathan Thorsen
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Casper-Emil Tingskov Pedersen
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Stokholm
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Dept of Pediatrics, Slagelse Sygehus, Slagelse, Denmark
| | - Klaus Bønnelykke
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Bo Chawes
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Hans Bisgaard
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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23
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Safiri S, Carson-Chahhoud K, Karamzad N, Sullman MJM, Nejadghaderi SA, Taghizadieh A, Bell AW, Kolahi AA, Ansarin K, Mansournia MA, Collins GS, Kaufman JS. Prevalence, Deaths, and Disability-Adjusted Life-Years Due to Asthma and Its Attributable Risk Factors in 204 Countries and Territories, 1990-2019. Chest 2022; 161:318-329. [PMID: 34699773 DOI: 10.1016/j.chest.2021.09.042] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/24/2021] [Accepted: 09/29/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Understanding global trends in the point prevalence, deaths, and disability-adjusted life-years (DALYs) for asthma will facilitate evidence-based decision-making. RESEARCH QUESTION What are the global, regional, and national burdens of asthma in 204 countries and territories between 1990 and 2019 by age, sex, and sociodemographic index (SDI)? STUDY DESIGN AND METHODS Publicly available data from the Global Burden of Disease study from 1990 through 2019 were used. All estimates were presented as counts and age-standardized rates per 100,000, along with their associated uncertainty intervals. RESULTS In 2019, the global age-standardized point prevalence and death rates for asthma were 3,415.5 and 5.8 per 100,000, which represent a 24% and 51.3% decrease since 1990, respectively. Moreover, in 2019, the global age-standardized DALY rate was 273.6 and the global point prevalence of asthma was highest in the group 5 to 9 years of age. Also in 2019, the United States (10,399.3) showed the highest age-standardized point prevalence rate of asthma. Generally, the burden of asthma decreased with increasing SDI. Globally, high BMI (16.9%), smoking (9.9%), and occupational asthmagens (8.8%) contributed to the 2019 asthma DALYs. INTERPRETATION Asthma remains an important public health issue, particularly in regions with low socioeconomic development. Future research is needed to examine thoroughly the associations asthma has with its risk factors and the factors impeding optimal self-management. Further research also is needed to understand and implement better the interventions that have reduced the burden of asthma.
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Affiliation(s)
- Saeid Safiri
- Tuberculosis and Lung Disease Research Center, Department of Community Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Tehran, Iran; Research Center for Integrative Medicine in Aging, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Tehran, Iran.
| | - Kristin Carson-Chahhoud
- Australian Centre for Precision Health, University of South Australia, Adelaide, SA, Australia; School of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Nahid Karamzad
- Nutrition Research Center, Department of Biochemistry and Diet Therapy, School of Nutrition and Food Sciences, Tabriz University of Medical Sciences, Tabriz, Tehran, Iran
| | - Mark J M Sullman
- Department of Life and Health Sciences, University of Nicosia, Nicosia, Cyprus; Department of Social Sciences, University of Nicosia, Nicosia, Cyprus
| | - Seyed Aria Nejadghaderi
- Research Center for Integrative Medicine in Aging, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Tehran, Iran; Systematic Review and Meta-analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Ali Taghizadieh
- Tuberculosis and Lung Disease Research Center, Department of Community Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Tehran, Iran
| | - Arielle Wilder Bell
- Health Sciences Integrated Program, Northwestern University, Chicago, IL; Department of Global Health and Social Medicine, Harvard University, Boston, MA
| | - Ali-Asghar Kolahi
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Khalil Ansarin
- Rahat Breath and Sleep Research Center, Tabriz University of Medical Sciences, Tabriz, Tehran, Iran
| | - Mohammad Ali Mansournia
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Gary S Collins
- Centre for Statistics in Medicine, NDORMS, Botnar Research Centre, University of Oxford, Oxford, England; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Jay S Kaufman
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, QC, Canada
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24
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Everard ML. Precision Medicine and Childhood Asthma: A Guide for the Unwary. J Pers Med 2022; 12:82. [PMID: 35055397 PMCID: PMC8779146 DOI: 10.3390/jpm12010082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 01/13/2023] Open
Abstract
Many thousands of articles relating to asthma appear in medical and scientific journals each year, yet there is still no consensus as to how the condition should be defined. Some argue that the condition does not exist as an entity and that the term should be discarded. The key feature that distinguishes it from other respiratory diseases is that airway smooth muscles, which normally vary little in length, have lost their stable configuration and shorten excessively in response to a wide range of stimuli. The lungs' and airways' limited repertoire of responses results in patients with very different pathologies experiencing very similar symptoms and signs. In the absence of objective verification of airway smooth muscle (ASM) lability, over and underdiagnosis are all too common. Allergic inflammation can exacerbate symptoms but given that worldwide most asthmatics are not atopic, these are two discrete conditions. Comorbidities are common and are often responsible for symptoms attributed to asthma. Common amongst these are a chronic bacterial dysbiosis and dysfunctional breathing. For progress to be made in areas of therapy, diagnosis, monitoring and prevention, it is essential that a diagnosis of asthma is confirmed by objective tests and that all co-morbidities are accurately detailed.
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Affiliation(s)
- Mark L Everard
- Division of Child Health, Children's Hospital, Faculty of Medicine, University of Western Australia, Perth, WA 6009, Australia
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25
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Jankauskaite L, Grechukha Y, Kjær KA, Mamenko M, Nakstad B, Romankevych I, Schnyder S, Selvakumar J, Trapani S, Daniliaviciene S, Valiulis A, Wyder C, Størdal K. Overuse of medical care in paediatrics: A survey from five countries in the European Academy of Pediatrics. Front Pediatr 2022; 10:945540. [PMID: 36177454 PMCID: PMC9513058 DOI: 10.3389/fped.2022.945540] [Citation(s) in RCA: 4] [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: 05/16/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
UNLABELLED Studies and initiatives such as the "Choosing wisely" (CW) campaign emphasise evidence-based investigations and treatment to avoid overdiagnosis and overtreatment. The perception of the extent of medical overactivity among professionals and drivers behind are not well studied in the paediatric field. AIM We aimed to investigate the physicians' opinion and clarify the main drivers regarding medical overactivity in member countries of the European Academy of Paediatrics (EAP). METHODS In this study, paediatricians, paediatric residents, primary care paediatricians, and family doctors treating children were surveyed in Norway, Lithuania, Ukraine, Italy, and Switzerland. Over-investigation was defined as "diagnostic work-up or referral that is unlikely to provide information which is relevant for a patient" and overtreatment was defined as "treatment that does not benefit or can harm more than benefit the patient." The original questionnaire was developed in 2018 by a working group from the Norwegian Paediatric Association. RESULTS Overall, 1,416 medical doctors participated in the survey, ranging from 144 in Lithuania to 337 in Switzerland. 83% stated that they experienced over-investigation/overtreatment, and 81% perceived this as a problem. The majority (83%) perceived expectations from family and patients as the most important driver for overtreatment in their country. Other drivers for overuse were use of national guidelines/recommendations, worry for reactions, and reduction of uncertainty. CONCLUSION This is the first study investigating knowledge and attitude toward medical overactivity in European countries. Despite different cultural and economic environments, the patterns and drivers of increased investigations and medicalisation are similar.
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Affiliation(s)
- Lina Jankauskaite
- Department of Paediatrics, Lithuanian University of Health Sciences, Kaunas, Lithuania.,Institute of Physiology and Pharmacology, Lithuanian University of Health Sciences, Kaunas, Lithuania.,European Academy of Paediatrics, Brussels, Belgium
| | - Yevgenii Grechukha
- European Academy of Paediatrics, Brussels, Belgium.,Department of Paediatric Infectious Diseases and Paediatric Immunology, Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine
| | | | - Marina Mamenko
- European Academy of Paediatrics, Brussels, Belgium.,Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine.,Ukrainian Academy of Paediatric Specialties, Kyiv, Ukraine
| | - Britt Nakstad
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Department of Paediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
| | - Ivanna Romankevych
- European Academy of Paediatrics, Brussels, Belgium.,Ukrainian Academy of Paediatric Specialties, Kyiv, Ukraine.,Miller School of Medicine, Jackson Memorial Hospital, University of Miami, Coral Gables, FL, United States
| | - Sara Schnyder
- European Academy of Paediatrics, Brussels, Belgium.,Division of Paediatric Emergency Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joel Selvakumar
- Department of Paediatric and Adolescent Health, Akershus University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Sandra Trapani
- European Academy of Paediatrics, Brussels, Belgium.,Paediatric Unit, Department of Health Sciences, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Sandra Daniliaviciene
- Karoliniskiu Policlinic, Vilnius, Lithuania.,Clinic of Children's Diseases, Institute of Clinical Medicine, Medical Faculty of Vilnius University, Vilnius, Lithuania
| | - Arunas Valiulis
- European Academy of Paediatrics, Brussels, Belgium.,Clinic of Children's Diseases, Institute of Clinical Medicine, Medical Faculty of Vilnius University, Vilnius, Lithuania.,Human Ecology Research Group, Department of Public Health, Institute of Health Sciences, Medical Faculty of Vilnius University, Vilnius, Lithuania
| | - Corinne Wyder
- European Academy of Paediatrics, Brussels, Belgium.,Paediatric Praxis Kurwerk, Burgdorf, Switzerland
| | - Ketil Størdal
- European Academy of Paediatrics, Brussels, Belgium.,Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Department of Paediatric Research, University of Oslo, Oslo, Norway
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26
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Attanasi M, Sferrazza Papa S, Porreca A, Sferrazza Papa GF, Di Filippo P, Piloni F, Dodi G, Sansone F, Di Pillo S, Chiarelli F. Use of lung ultrasound in school-aged children with wheezing. Front Pediatr 2022; 10:926252. [PMID: 36699291 PMCID: PMC9869023 DOI: 10.3389/fped.2022.926252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 12/08/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND There is limited information available on fast and safe bedside tools that could help clinicians establish whether the pathological process underlying cases of wheezing is due to asthmatic exacerbation, asthmatic bronchitis, or pneumonia. The study's aim was to characterize Lung Ultrasound (LUS) in school-aged children with wheezing and evaluate its use for their follow-up treatment. MATERIALS AND METHODS We carried out a cross-sectional study involving 68 consecutive outpatients (mean age 9.9 years) with wheezing and suggestive signs of an acute respiratory infection. An expert sonographer, blinded to all subject characteristics, clinical course, and the study pediatrician's diagnosis, performed an LUS after spirometry and before BDT. The severity of acute respiratory symptoms was determined using the Pediatric Respiratory Assessment Measure (PRAM) score. RESULTS The LUS was positive in 38.2% (26/68) of patients [12 (46.1%) with multiple B-lines, 24 (92.3%) with consolidation, and 22 (84.6%) with pleural abnormalities]. In patients with pneumonia, asthmatic bronchitis, and asthma, the percentages of those patients with a positive LUS were 100%, 57.7%, and 0%, respectively. Of note, patients with a positive LUS were associated with an increased need for hospital admission (30.8% vs. 2.4%, p = 0.001), administration of oxygen therapy (14.6% vs. 0%, p = 0.009), oral corticosteroids (84.6% vs. 19.0%, p < 0.001), and antibiotics (88.5% vs. 11.9%, p < 0.001); and a higher median value of PRAM score (4.0 (2.0-7.0) vs. 2.0 (1.0-5.0); p < 0.001). CONCLUSIONS Our findings would suggest the use of LUS as a safe and cheap tool used by clinicians to define the diagnosis of school-aged children with wheezing of unknown causes.
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Affiliation(s)
- Marina Attanasi
- Department of Pediatrics, Pediatric Allergy and Pulmonology Unit, University of Chieti-Pescara, Chieti, Italy
| | - Simone Sferrazza Papa
- Department of Pediatrics, Pediatric Allergy and Pulmonology Unit, University of Chieti-Pescara, Chieti, Italy
| | - Annamaria Porreca
- Department of Economic Studies, University of Chieti-Pescara, Chieti, Italy
| | - Giuseppe F Sferrazza Papa
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy.,Department of Neurorehabilitation Sciences, Casa di Cura del Policlinico, Milan, Italy
| | - Paola Di Filippo
- Department of Pediatrics, Pediatric Allergy and Pulmonology Unit, University of Chieti-Pescara, Chieti, Italy
| | - Francesca Piloni
- Department of Pediatrics, Pediatric Allergy and Pulmonology Unit, University of Chieti-Pescara, Chieti, Italy
| | - Giulia Dodi
- Department of Pediatrics, Pediatric Allergy and Pulmonology Unit, University of Chieti-Pescara, Chieti, Italy
| | - Francesco Sansone
- Department of Pediatrics, Pediatric Allergy and Pulmonology Unit, University of Chieti-Pescara, Chieti, Italy
| | - Sabrina Di Pillo
- Department of Pediatrics, Pediatric Allergy and Pulmonology Unit, University of Chieti-Pescara, Chieti, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, Pediatric Allergy and Pulmonology Unit, University of Chieti-Pescara, Chieti, Italy
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27
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Caesarean delivery and risk of childhood asthma development: meta-analysis. Postepy Dermatol Alergol 2021; 38:819-826. [PMID: 34849130 PMCID: PMC8610062 DOI: 10.5114/ada.2020.96703] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/19/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Several studies indicate that delivery by caesarean section may be one of the risk factors for the development of childhood asthma. Aim A meta-analysis was carried out to establish the relationship between delivery by caesarean section and asthma in children. Material and methods After a review of bibliographic databases, 41 articles were obtained and 12 of which were accepted for further analysis. The odds ratios (OR) included in the analysis were specified on the basis of data from the presented studies or were calculated using reported prevalence. The analysis took into account unadjusted OR. The heterogeneity of results was assessed using the χ2 test, determining p < 0.05 as the level of significance. The analysis was performed using Statistica 13.3 and kit 4.0.67. Results Caesarean delivery was associated with an increased risk of development of childhood asthma (OR = 1.41); however, significant heterogeneity of results was demonstrated. A significantly higher risk of asthma was found in children born by caesarean section in the case where the disease was confirmed in a questionnaire-based study (OR = 1.26, 95% CI: 1.05-1.5), and the results of that study were homogeneous. Conclusions In the case of the diagnosis of asthma declared by parents in the questionnaire-based study, a significantly higher risk of disease occurrence was observed in children born by caesarean section. Due to the significant heterogeneity of the results of the studies, it cannot be clearly stated that caesarean delivery is a risk factor for the development of bronchial asthma.
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Bush A. Impact of early life exposures on respiratory disease. Paediatr Respir Rev 2021; 40:24-32. [PMID: 34144911 DOI: 10.1016/j.prrv.2021.05.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/20/2021] [Indexed: 12/21/2022]
Abstract
The antecedents of asthma and chronic obstructive pulmonary disease (COPD) lie before school age. Adverse effects are transgenerational, antenatal and in the preschool years. Antenatal adverse effects impair spirometry by causing low birth weight, altered lung structure and immune function, and sensitizing the foetus to later insults. The key stages of normal lung health are lung function at birth, lung growth to a plateau age 20-25 years, and the phase of decline thereafter; contrary to perceived wisdom, accelerated decline is not related to smoking. There are different trajectories of lung function. Lung function usually tracks from preschool to late middle age. Asthma is driven by antenatal and early life influences. The airflow obstruction, emphysema and multi-morbidity of COPD all start early. Failure to reach a normal plateau and accelerated decline in lung function are risk factors for COPD. Airway disease cannot be prevented in adult life; prevention must start early.
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Affiliation(s)
- Andrew Bush
- Paediatrics and Paediatric Respirology, Imperial College, UK; Imperial Centre for Paediatrics and Child Health, UK; Consultant Paediatric Chest Physician, Royal Brompton Harefield NHS Foundation Trust, UK.
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Al Shamrani A, AlShammari A, AlAlkami H, AlShanwani J, Alharbi AS. When is asthma not guilty? Int J Pediatr Adolesc Med 2021; 8:203-211. [PMID: 34401444 PMCID: PMC8356124 DOI: 10.1016/j.ijpam.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/12/2020] [Accepted: 10/18/2020] [Indexed: 11/20/2022]
Abstract
Asthma is a common childhood condition. Its prevalence in Saudi Arabia is high, increasing, and could exceed 20% at the current trajectory. Asthma is a syndrome with different clinical presentations and phenotypes. Many conditions are often misdiagnosed as asthma because they share the same symptoms, particularly coughing and shortness of breath; physical findings, such as wheezing; radiological findings, such as hyperinflation on chest X-ray; or even responses to asthma therapies, as in some patients with bronchiolitis. When treating the younger age group (>5 years old), there should be a high degree of suspicion of alternative causes when evaluating patients presenting with clinical features suggestive of asthma or patients who do not respond well to asthma therapies. This study will highlight common conditions that may mimic asthma and, as a result of incorrect treatment, unnecessarily expose patients to steroids and other therapies for extended periods. Furthermore, we seek to alert healthcare providers to common symptoms and signs that suggest a cause other than asthma and suggest when to refer the patient to subspecialists.
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Affiliation(s)
| | - Ayshah AlShammari
- Department of Pediatrics, Prince Sultan Military Medical City, Saudi Arabia
| | - Halima AlAlkami
- Department of Pediatrics, Prince Sultan Military Medical City, Saudi Arabia
| | - Jawaher AlShanwani
- Department of Pediatrics, Prince Sultan Military Medical City, Saudi Arabia
| | - Adel S. Alharbi
- Department of Pediatrics, Prince Sultan Military Medical City, Saudi Arabia
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Porter P, Brisbane J, Tan J, Bear N, Choveaux J, Della P, Abeyratne U. Diagnostic Errors Are Common in Acute Pediatric Respiratory Disease: A Prospective, Single-Blinded Multicenter Diagnostic Accuracy Study in Australian Emergency Departments. Front Pediatr 2021; 9:736018. [PMID: 34869099 PMCID: PMC8637207 DOI: 10.3389/fped.2021.736018] [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] [Received: 07/04/2021] [Accepted: 10/14/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Diagnostic errors are a global health priority and a common cause of preventable harm. There is limited data available for the prevalence of misdiagnosis in pediatric acute-care settings. Respiratory illnesses, which are particularly challenging to diagnose, are the most frequent reason for presentation to pediatric emergency departments. Objective: To evaluate the diagnostic accuracy of emergency department clinicians in diagnosing acute childhood respiratory diseases, as compared with expert panel consensus (reference standard). Methods: Prospective, multicenter, single-blinded, diagnostic accuracy study in two well-resourced pediatric emergency departments in a large Australian city. Between September 2016 and August 2018, a convenience sample of children aged 29 days to 12 years who presented with respiratory symptoms was enrolled. The emergency department discharge diagnoses were reported by clinicians based upon standard clinical diagnostic definitions. These diagnoses were compared against consensus diagnoses given by an expert panel of pediatric specialists using standardized disease definitions after they reviewed all medical records. Results: For 620 participants, the sensitivity and specificity (%, [95% CI]) of the emergency department compared with the expert panel diagnoses were generally poor: isolated upper respiratory tract disease (64.9 [54.6, 74.4], 91.0 [88.2, 93.3]), croup (76.8 [66.2, 85.4], 97.9 [96.2, 98.9]), lower respiratory tract disease (86.6 [83.1, 89.6], 92.9 [87.6, 96.4]), bronchiolitis (66.9 [58.6, 74.5], 94.3 [80.8, 99.3]), asthma/reactive airway disease (91.0 [85.8, 94.8], 93.0 [90.1, 95.3]), clinical pneumonia (63·9 [50.6, 75·8], 95·0 [92·8, 96·7]), focal (consolidative) pneumonia (54·8 [38·7, 70·2], 86.2 [79.3, 91.5]). Only 59% of chest x-rays with consolidation were correctly identified. Between 6.9 and 14.5% of children were inappropriately prescribed based on their eventual diagnosis. Conclusion: In well-resourced emergency departments, we have identified a previously unrecognized high diagnostic error rate for acute childhood respiratory disorders, particularly in pneumonia and bronchiolitis. These errors lead to the potential of avoidable harm and the administration of inappropriate treatment.
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Affiliation(s)
- Paul Porter
- Department of Paediatrics, Joondalup Health Campus, Joondalup, WA, Australia
- PHI Research Group, Joondalup Health Campus, Joondalup, WA, Australia
- School of Nursing, Midwifery and Paramedicine, Curtin University, Bentley, WA, Australia
| | - Joanna Brisbane
- Department of Paediatrics, Joondalup Health Campus, Joondalup, WA, Australia
- PHI Research Group, Joondalup Health Campus, Joondalup, WA, Australia
| | - Jamie Tan
- Department of Paediatrics, Joondalup Health Campus, Joondalup, WA, Australia
| | - Natasha Bear
- Institute of Health Research, University of Notre Dame, Fremantle, WA, Australia
| | - Jennifer Choveaux
- Department of Paediatrics, Joondalup Health Campus, Joondalup, WA, Australia
- PHI Research Group, Joondalup Health Campus, Joondalup, WA, Australia
| | - Phillip Della
- School of Nursing, Midwifery and Paramedicine, Curtin University, Bentley, WA, Australia
| | - Udantha Abeyratne
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
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Fernández-Gutiérrez F, Kennedy JI, Cooksey R, Atkinson M, Choy E, Brophy S, Huo L, Zhou SM. Mining Primary Care Electronic Health Records for Automatic Disease Phenotyping: A Transparent Machine Learning Framework. Diagnostics (Basel) 2021; 11:diagnostics11101908. [PMID: 34679609 PMCID: PMC8534858 DOI: 10.3390/diagnostics11101908] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/06/2021] [Accepted: 10/13/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: We aimed to develop a transparent machine-learning (ML) framework to automatically identify patients with a condition from electronic health records (EHRs) via a parsimonious set of features. (2) Methods: We linked multiple sources of EHRs, including 917,496,869 primary care records and 40,656,805 secondary care records and 694,954 records from specialist surgeries between 2002 and 2012, to generate a unique dataset. Then, we treated patient identification as a problem of text classification and proposed a transparent disease-phenotyping framework. This framework comprises a generation of patient representation, feature selection, and optimal phenotyping algorithm development to tackle the imbalanced nature of the data. This framework was extensively evaluated by identifying rheumatoid arthritis (RA) and ankylosing spondylitis (AS). (3) Results: Being applied to the linked dataset of 9657 patients with 1484 cases of rheumatoid arthritis (RA) and 204 cases of ankylosing spondylitis (AS), this framework achieved accuracy and positive predictive values of 86.19% and 88.46%, respectively, for RA and 99.23% and 97.75% for AS, comparable with expert knowledge-driven methods. (4) Conclusions: This framework could potentially be used as an efficient tool for identifying patients with a condition of interest from EHRs, helping clinicians in clinical decision-support process.
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Affiliation(s)
- Fabiola Fernández-Gutiérrez
- Swansea University Medical School, Swansea University, Swansea SA2 8PP, UK; (F.F.-G.); (J.I.K.); (R.C.); (M.A.); (S.B.)
| | - Jonathan I. Kennedy
- Swansea University Medical School, Swansea University, Swansea SA2 8PP, UK; (F.F.-G.); (J.I.K.); (R.C.); (M.A.); (S.B.)
| | - Roxanne Cooksey
- Swansea University Medical School, Swansea University, Swansea SA2 8PP, UK; (F.F.-G.); (J.I.K.); (R.C.); (M.A.); (S.B.)
| | - Mark Atkinson
- Swansea University Medical School, Swansea University, Swansea SA2 8PP, UK; (F.F.-G.); (J.I.K.); (R.C.); (M.A.); (S.B.)
| | - Ernest Choy
- Arthritis Research UK CREATE Centre, Division Infection and Immunity, Cardiff University, Cardiff CF10 3NB, UK;
- Welsh Arthritis Research Network, School of Medicine, Cardiff University, Cardiff CF10 3NB, UK
| | - Sinead Brophy
- Swansea University Medical School, Swansea University, Swansea SA2 8PP, UK; (F.F.-G.); (J.I.K.); (R.C.); (M.A.); (S.B.)
| | - Lin Huo
- China-ASEAN Research Institute, Guangxi University, Nanning 530004, China;
| | - Shang-Ming Zhou
- Centre for Health Technology, Faculty of Health, University of Plymouth, Plymouth PL4 8AA, UK
- Correspondence: or
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Castro-Rodriguez JA, Forno E, Padilla O, Casanello P, Krause BJ, Borzutzky A. The asthma predictive index as a surrogate diagnostic tool in preschoolers: Analysis of a longitudinal birth cohort. Pediatr Pulmonol 2021; 56:3183-3188. [PMID: 34320686 PMCID: PMC10772975 DOI: 10.1002/ppul.25592] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/18/2021] [Accepted: 07/15/2021] [Indexed: 11/12/2022]
Abstract
Diagnosing asthma in preschool children remains an unsolved challenge, at a time when early identification would allow for better education and treatment to prevent morbidity and lung function deterioration. OBJECTIVE To evaluate if the asthma predictive index (API) can be used as surrogate for asthma diagnosis in preschoolers. METHODS Birth cohort of 339 pregnant women enrolled at delivery and their offspring, who were followed for atopy, wheezing, and other respiratory illnesses through 30 months of age. The API was determined at 30 months of age by the researchers; and examined its association with physician-diagnosed asthma during the first 30 months, made independently by the primary care physician not involved in the study. RESULTS Among 307 offspring with complete follow-up, 44 (14.3%) were API+. Maternal body mass index, maternal education, past oral contraceptive use, birthweight, placenta weight, age of daycare at 12 m, gastroesophageal reflux disease at 12 m, acute otitis media at 18 m, bronchiolitis, croup and pneumonia, cord blood adiponectin were all associated with API+. In the multivariable analysis, API+ was associated with almost sixfold odds of asthma diagnosis (adjusted OR = 5.7, 95% CI [2.6-12.3]), after adjusting for the relevant covariates above including respiratory infections like bronchiolitis and pneumonia. The API sensitivity was 48%, specificity 92%, 61% PPV, 88% NPV, 6.4 LR+, 0.56 LR-, 0.84 diagnosis accuracy. The adjusted odds for asthma was 11.4. CONCLUSIONS This longitudinal birth cohort suggests, for first time, that API (a structured definition for asthma), could be used as a diagnostic tool, not only as a prognostic tool, in toddlers and preschoolers.
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Affiliation(s)
- Jose A Castro-Rodriguez
- Division of Pediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Erick Forno
- Division of Pulmonary Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Oslando Padilla
- Department of Public Health, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Paola Casanello
- Division of Pediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Obstetrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Bernardo J Krause
- Instituto de Ciencias de la Salud, Universidad de O'Higgins, Rancagua, Chile
| | - Arturo Borzutzky
- Division of Pediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Pediatric Infectious Diseases, and Millennium Institute on Immunology and Immunotherapy, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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Bush A, Pavord ID. Challenging the paradigm: moving from umbrella labels to treatable traits in airway disease. Breathe (Sheff) 2021; 17:210053. [PMID: 35035544 PMCID: PMC8753662 DOI: 10.1183/20734735.0053-2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/11/2021] [Indexed: 12/15/2022] Open
Abstract
Airway diseases were initially described by nonspecific patterns of symptoms, for example "dry and wheezy" and "wet and crackly". The model airway disease is cystic fibrosis, which has progressed from nonspecific reactive treatments such as antibiotics for airway infection to molecular sub-endotype, proactive therapies with an unequivocal evidence base, early diagnosis, and biomarkers of treatment efficacy. Unfortunately, other airway diseases lag behind, not least because nonspecific umbrella labels such as "asthma" are considered to be diagnoses not mere descriptions. Pending the delineation of molecular sub-endotypes in other airway disease the concept of treatable traits, and consideration of airway disease in a wider context is preferable. A treatable trait is a characteristic amenable to therapy, with measurable benefits of treatment. This approach determines what pathology is actually present and treatable, rather than using umbrella labels. We determine if airway inflammation is present, and whether there is airway eosinophilia which will likely respond to inhaled corticosteroids; whether there is variable airflow obstruction due to bronchoconstriction which will respond to β2-agonists; and whether there is unsuspected underlying airway infection which should be treated with antibiotics unless there is an underlying endotype which can be addressed, as for example an immunodeficiency. The context of airway disease should also be extrapulmonary comorbidities, social and environmental factors, and a developmental perspective, particularly this last aspect if preventive strategies are being contemplated. This approach allows targeted treatment for maximal patient benefit, as well as preventing the discarding of therapies which are useful for appropriate subgroups of patients. Failure to appreciate this almost led to the discarding of valuable treatments such as prednisolone. EDUCATIONAL AIMS To use cystic fibrosis as a paradigm to show the benefits of the journey from nonspecific umbrella terms to specific endotypes and sub-endotypes, as a road map for other airway diseases to follow.Demonstrate that nonspecific labels to describe airway disease can and should be abandoned in favour of treatable traits to ensure diagnostic and therapeutic precision.Begin to learn to see airway disease in the context of extrapulmonary comorbidities, and social and environmental factors, as well as with a developmental perspective.
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Affiliation(s)
- Andrew Bush
- Paediatrics and Paediatric Respirology, Imperial Centre for Paediatrics and Child Health, Imperial College London, London, UK
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ian D. Pavord
- Respiratory Medicine, Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
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Prime SJ, Carter HE, McPhail SM, Petsky HL, Chang AB, Graves N, Marchant JM. Chronic wet cough in Australian children: Societal costs and quality of life. Pediatr Pulmonol 2021; 56:2707-2716. [PMID: 33939893 DOI: 10.1002/ppul.25438] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/13/2021] [Accepted: 04/12/2021] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Children with chronic wet cough regularly use the health system, experience considerable variability in care, have reduced quality of life (QoL), and, left untreated, poorer health outcomes. Despite this, little is known about the associated economic burden. This study aimed to quantify the cost of chronic wet cough among Australian children from the perspectives of families and the health system. METHODS A cost of illness study was conducted at the Queensland Children's Hospital, Brisbane, using data on 91 children newly referred to a respiratory specialist between July 2015 and January 2017 with a history of chronic wet cough (>4 weeks) of unknown etiology. Administrative and parent-reported data were used to estimate costs (reported in 2019 Australian Dollars [AUD]) for up to 12 months before and following initial pulmonology consultation. QoL was assessed for the same periods. RESULTS Mean cost per child-month during the average 9.8 months of observation preceding pulmonology consultation was AUD689 (95% confidence interval [CI] 534-844) increasing to AUD1339 (95% CI 1051-1628) during the average 11.9 months following pulmonology consultation. This translated to a total of AUD1.9 million across the study period, with families bearing 26.4% of costs. Aspiration and bronchiectasis were associated with higher total costs. For all etiologies, cough-specific QoL improved following pulmonology consultation, while direct medical costs declined. CONCLUSION Childhood chronic wet cough is associated with substantial societal costs. The observed cost decrease after specialist diagnosis suggests that early referral to a respiratory specialist may have economic benefits, in addition to the known health benefits.
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Affiliation(s)
- Samantha J Prime
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Hannah E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia.,Clinical Informatics Directorate, Metro South Health, Woolloongabba, Queensland, Australia
| | - Helen L Petsky
- School of Nursing and Midwifery, Griffith University and Menzies Health Institute Queensland, Brisbane, Queensland, Australia
| | - Anne B Chang
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia.,Child Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Nicholas Graves
- Health Service and Systems Research Program, Duke-NUS Medical School, Singapore
| | - Julie M Marchant
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
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Severcan EU, Bal CM, Tanac R, Gulen F, Demir E. Retrospective Cross-sectional Analysis of Factors Associated with Asthma in a Pediatric Cohort from Turkey. KLINISCHE PADIATRIE 2021; 234:14-19. [PMID: 34331302 DOI: 10.1055/a-1500-8264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND It is difficult to identify young children at increased risk of developing asthma amongst those with recurrent wheezing. In this study, we aimed to determine factors associated with asthma in Turkish children. METHODS We performed a retrospective cross-sectional analysis on factors associated with asthma in 651 children (200 girls, 451 boys) admitted for recurrent wheezing. RESULTS Amongst all included children, asthma frequency was 57.7%. Maturity, consanguinity, family income, passive smoking, father's, siblings' asthma were not found to be associated with asthma. Factors associated with asthma were: family's, parents', siblings' atopy, family's, mother's asthma, allergic rhinitis and atopic dermatitis, respiratory symptoms between wheezing attacks. The sensitivity (SN) of the modified asthma predictive index (mAPI) was 59.2% with a specificity (SP) of 91.3%, positive predictive index (PPI) of 65.1% and negative predictive index (NPI) of 82.3%. The SN of the modified Prevention and Incidence of Asthma and Mite Allergy (PIAMA) score was 22.9% with a SP of 89.2%, PPI of 84.6%, and NPI of 42.2%. Adjusted odds ratio for mAPI was 12.9, and for the modified PIAMA score 4. CONCLUSION Our analysis confirmed previously described factors associated with asthma. Although the SN is limited, the mAPI and PIAMA risk scores can be used to predict asthma in Turkish children. Differential diagnoses and overlaps with other chronic pediatric diseases such as immunodeficiencies need to be carefully excluded when confirming the diagnosis asthma.
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Affiliation(s)
- Ezgi Ulusoy Severcan
- Department of Pediatric Immunology and Allergy, Ege University Faculty of Medicine, Izmir, Turkey
| | - Cem Murat Bal
- Department of Pediatric Pulmonology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Remziye Tanac
- Department of Pediatric Immunology and Allergy, Ege University Faculty of Medicine, Izmir, Turkey
| | - Figen Gulen
- Department of Pediatric Immunology and Allergy, Ege University Faculty of Medicine, Izmir, Turkey
| | - Esen Demir
- Department of Pediatric Immunology and Allergy, Ege University Faculty of Medicine, Izmir, Turkey
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Pade KH, Thompson LR, Ravandi B, Chang TP, Barry F, Halterman JS, Szilagyi PG, Okelo SO. Children with under-diagnosed asthma presenting to a pediatric emergency department. J Asthma 2021; 59:1353-1359. [PMID: 34034597 DOI: 10.1080/02770903.2021.1934696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Undiagnosed asthma in children presenting to the emergency department (ED) for respiratory illnesses might be associated with subsequent asthma morbidity and repeat ED visits. OBJECTIVE To examine the prevalence of undiagnosed asthma among children presenting for ED care, and explore associations with sociodemographic and clinical characteristics. METHODS We surveyed parents of children ages 2-17 years seeking ED care for respiratory symptoms (including asthma) regarding sociodemographic characteristics, asthma symptoms, prior asthma care and morbidity, and prior asthma diagnosis. Undiagnosed asthma was defined as a positive screening for asthma and no prior diagnosis. We compared sociodemographic and clinical factors of those with diagnosed versus undiagnosed asthma using chi-square, t-tests and multivariable logistic regression model. RESULTS Of 362 children, 36% had undiagnosed asthma. Undiagnosed children were younger, had younger parents, and had parents less likely to speak English versus diagnosed children (all p < 0.05). Among undiagnosed children, 42% had moderate or severe asthma and 66% reported ≥1 exacerbation in the prior 12 months. Parent-reported controller medication use was higher among diagnosed versus undiagnosed children (60% vs. 21%, p=.001). In a multivariable logistic regression (adjusting for insurance, education, income and preferred language), no controller usage (aOR 4.26), no asthma exacerbations in the prior year (aOR 2.41) and younger age (aOR 0.76) were significantly associated with undiagnosed asthma. CONCLUSION Children presenting to the ED with undiagnosed asthma commonly experience significant prior asthma morbidity. Strategies to improve asthma diagnosis and messaging to their parents may reduce future morbidity.
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Affiliation(s)
- Kathryn H Pade
- Rady Children's Hospital San Diego, UCSD School of Medicine, San Diego, CA, USA
| | | | - Bahareh Ravandi
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Todd P Chang
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Frances Barry
- UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | | | | | - Sande O Okelo
- UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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Severcan EU, Bal CM, Gülen F, Tanaç R, Demir E. Identifying wheezing phenotypes in a pediatric Turkish cohort. J Asthma 2021; 59:1298-1304. [PMID: 33906564 DOI: 10.1080/02770903.2021.1922916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Characterization of wheezing phenotypes in children might help to identify the underlying mechanisms through which asthma occurs. In our study, we aimed to describe wheezing phenotypes in Turkish children and to identify risk factors according to phenotypes. METHODS 651 wheezy children were evaluated and 5 wheezing phenotypes were described according to age of onset, atopy and persistence at 6 years of age and risk factors were identified. RESULTS Distribution of wheezing phenotypes was transient early wheeze (TEW)(34.9%) non-atopic wheeze (NAW) (18%), atopic wheeze (AW) (22.3%), intermediate onset wheeze (IOW) (11.1%), late onset wheeze (LOW) (11.7%). LOW, AW, and IOW were associated with, father's, sibling's and family's atopy (p:0.001) whereas LOW and AW were associated with mother's asthma and atopy as well as family's asthma (p < 0.05). Atopic dermatitis and allergic rhinitis were common of patients with LOW, AW, and IOW (p < 0.05). İnfection was the major trigger for TEW and NAW whereas multiple triggers were common of AW, LOW, and IOW. Allergens were mostly associated with AW, IOW and LOW. Aeroallergen-specific IgE positivity was mostly with AW, IOW, and LOW phenotype. Skin prick tests showed multiple allergen sensitivity in IOW, LOW groups and mostly single allergen in AW phenotype. Modified asthma predictive index (mAPI) positivity was high in all groups except TEW and NAW. CONCLUSIONS With this study we classified five wheeze phenotypes and found that atopy and family's atopy history, maternal asthma were strongly associated with AW, LOW, and IOW phenotypes which were usually effected by allergens or multiple triggers.
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Affiliation(s)
- Ezgi Ulusoy Severcan
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Cem Murat Bal
- Department of Pediatrics, Division of Pediatric Pulmonology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Figen Gülen
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Remziye Tanaç
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Esen Demir
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Ege University Faculty of Medicine, İzmir, Turkey
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Stromberga Z, Phelps C, Smith J, Moro C. Teaching with Disruptive Technology: The Use of Augmented, Virtual, and Mixed Reality (HoloLens) for Disease Education. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1317:147-162. [PMID: 33945136 DOI: 10.1007/978-3-030-61125-5_8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Modern technologies are often utilised in schools or universities with a variety of educational goals in mind. Of particular interest is the enhanced interactivity and engagement offered by mixed reality devices such as the HoloLens, as well as the ability to explore anatomical models of disease using augmented and virtual realities. As the students are required to learn an ever-increasing number of diseases within a university health science or medical degree, it is crucial to consider which technologies provide value to educators and students. This chapter explores the opportunities for using modern disruptive technologies to teach a curriculum surrounding disease. For relevant examples, a focus will be placed on asthma as a respiratory disease which is increasing in prevalence, and stroke as a neurological and cardiovascular disease. The complexities of creating effective educational curricula around these diseases will be explored, along with the benefits of using augmented reality and mixed reality as viable teaching technologies in a range of use cases.
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Affiliation(s)
- Zane Stromberga
- Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| | - Charlotte Phelps
- Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| | - Jessica Smith
- Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| | - Christian Moro
- Faculty of Health Sciences and Medicine, Bond University, Robina, Australia.
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Gaillard EA, Moeller A. Evidence-based European guidelines for the diagnosis of asthma in children aged 5-16 years. THE LANCET RESPIRATORY MEDICINE 2021; 9:558-560. [PMID: 33894141 DOI: 10.1016/s2213-2600(21)00183-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 04/08/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Erol A Gaillard
- Department of Respiratory Sciences, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester LE2 7LX, UK; Department of Paediatric Respiratory Medicine, Leicester Children's Hospital, University Hospitals Leicester, Leicester, UK.
| | - Alexander Moeller
- Division of Respiratory Medicine, University Children's Hospital Zurich and Childhood Research Center, Zurich, Switzerland
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Gaillard EA, Kuehni CE, Turner S, Goutaki M, Holden KA, de Jong CCM, Lex C, Lo DKH, Lucas JS, Midulla F, Mozun R, Piacentini G, Rigau D, Rottier B, Thomas M, Tonia T, Usemann J, Yilmaz O, Zacharasiewicz A, Moeller A. European Respiratory Society clinical practice guidelines for the diagnosis of asthma in children aged 5-16 years. Eur Respir J 2021; 58:13993003.04173-2020. [PMID: 33863747 DOI: 10.1183/13993003.04173-2020] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 03/15/2021] [Indexed: 11/05/2022]
Abstract
Diagnosing asthma in children represents an important clinical challenge. There is no single gold standard test to confirm the diagnosis. Consequently, both over-, and under-diagnosis of asthma are frequent in children.A Task Force (TF) supported by the European Respiratory Society has developed these evidence-based clinical practice guidelines for the diagnosis of asthma in children aged 5-16 years using nine PICO (Population, Intervention, Comparator and Outcome) questions. The TF conducted systematic literature searches for all PICO questions and screened the outputs from these, including relevant full text articles. All TF members approved the final decision for inclusion of research papers. The TF assessed the quality of the evidence using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach.The TF then developed a diagnostic algorithm based on the critical appraisal of the PICO questions, preferences expressed by lay members and test availability. Proposed cut-offs were determined based on the best available evidence. The TF formulated recommendations using the GRADE Evidence to Decision framework.Based on the critical appraisal of the evidence and the Evidence to Decision Framework the TF recommends spirometry, bronchodilator reversibility testing and FeNO as first line diagnostic tests in children under investigation for asthma. The TF recommends against diagnosing asthma in children based on clinical history alone or following a single abnormal objective test. Finally, this guideline also proposes a set of research priorities to improve asthma diagnosis in children in the future.
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Affiliation(s)
- Erol A Gaillard
- Department of Respiratory Sciences, Leicester NIHR Biomedical Research Centre (Respiratory theme), University of Leicester, Leicester, UK .,Department of Paediatric Respiratory Medicine, Leicester Children's Hospital, University Hospitals Leicester, Leicester, UK
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Paediatric Respiratory Medicine, Children's University Children's Hospital, University of Bern, Bern, Switzerland
| | - Steve Turner
- Child Health, University of Aberdeen, Aberdeen, UK
| | - Myrofora Goutaki
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Paediatric Respiratory Medicine, Children's University Children's Hospital, University of Bern, Bern, Switzerland
| | - Karl A Holden
- Department of Respiratory Sciences, Leicester NIHR Biomedical Research Centre (Respiratory theme), University of Leicester, Leicester, UK
| | - Carmen C M de Jong
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Christiane Lex
- Department of Paediatric Cardiology, Intensive Care Medicine and Neonatology with Paediatric Pulmonology, University Medical Center Goettingen, Goettingen, Germany
| | - David K H Lo
- Department of Respiratory Sciences, Leicester NIHR Biomedical Research Centre (Respiratory theme), University of Leicester, Leicester, UK.,Department of Paediatric Respiratory Medicine, Leicester Children's Hospital, University Hospitals Leicester, Leicester, UK
| | - Jane S Lucas
- Primary Ciliary Dyskinesia Centre, National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,University of Southampton Faculty of Medicine, School of Clinical and Experimental Medicine, Southampton, UK
| | - Fabio Midulla
- Maternal-Science Department, Sapienza University of Rome, Rome, Italy
| | - Rebeca Mozun
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Giorgio Piacentini
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - David Rigau
- Iberoamerican Cochrane Centre, Barcelona, Spain
| | - Bart Rottier
- Department of Paediatric Pulmonology and Paediatric Allergology, University Medical Centre Groningen, Beatrix Children's Hospital, University of Groningen, Groningen, The Netherlands.,University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands; Groningen Research Institute for Asthma and COPD, (GRIAC), Groningen, The Netherlands
| | - Mike Thomas
- Primary Care, Population Sciences and Medical Education (PPM), Faculty of Medicine, University of Southampton, Southampton, UK
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Jakob Usemann
- University Children's Hospital Basel (UKBB), Basel, Switzerland.,Division of Respiratory Medicine, University Children's Hospital Zuerich and Childhood Research Center, Zuerich, Switzerland
| | - Ozge Yilmaz
- Department of Pediatric Allergy and Pulmonology, Celal Bayar University, Manisa, Turkey
| | - Angela Zacharasiewicz
- Department of Pediatrics and Adolescent Medicine, Wilhelminenspital, Teaching Hospital of the University of Vienna, Vienna, Austria
| | - Alexander Moeller
- Division of Respiratory Medicine, University Children's Hospital Zuerich and Childhood Research Center, Zuerich, Switzerland
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Dubovyi A, Chelimo C, Schierding W, Bisyuk Y, Camargo CA, Grant CC. A systematic review of asthma case definitions in 67 birth cohort studies. Paediatr Respir Rev 2021; 37:89-98. [PMID: 32653466 DOI: 10.1016/j.prrv.2019.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 12/23/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Birth cohort studies are a valuable source of information about potential risk factors for childhood asthma. To better understand similarities and variations in findings between birth cohort studies, the methodologies used to measure asthma require consideration. OBJECTIVE To review and appraise the definitions of "asthma" used in birth cohort studies. METHODS A literature search, conducted in December 2017 in the MEDLINE database and birth cohort repositories, identified 1721 citations published since 1990. Information extracted included: study name, year of publication, sample size, sample age, prevalence of asthma (%), study region, source of information about asthma, measured outcome, and asthma case definition. A meta-analysis evaluated whether asthma prevalence in cohorts from Europe and North America varied by the studies' definition of asthma and by their data sources. RESULTS The final review included 67 birth cohorts, of which 48 (72%) were from Europe, 14 (21%) from North America, 3 (5%) from Oceania, 1 (1%) from Asia and 1 (1%) from South America. We identified three measured outcomes: "asthma ever", "current asthma", and "asthma" without further specification. Definitions of "asthma ever" were primarily based upon an affirmative parental response to the question whether the child had ever been diagnosed with asthma by a physician. The most frequently used definition of "current asthma" was "asthma ever" and either asthma symptoms or asthma medications in the last 12 months. This definition of "current asthma" was used in 16 cohorts. There was no statistically significant difference in the pooled asthma prevalence in European and North American cohorts that used questionnaire alone versus other data sources to classify asthma. CONCLUSION There is substantial heterogeneity in childhood asthma definitions in birth cohort studies. Standardisation of asthma case definitions will improve the comparability and utility of future cohort studies and enable meta-analyses.
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Affiliation(s)
- Andrew Dubovyi
- Centre for Longitudinal Research, University of Auckland, Auckland, New Zealand; Department of Paediatrics: Child & Youth Health, University of Auckland, Auckland, New Zealand
| | - Carol Chelimo
- Department of Paediatrics: Child & Youth Health, University of Auckland, Auckland, New Zealand
| | | | - Yuriy Bisyuk
- Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine
| | - Carlos A Camargo
- Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Cameron C Grant
- Centre for Longitudinal Research, University of Auckland, Auckland, New Zealand; Department of Paediatrics: Child & Youth Health, University of Auckland, Auckland, New Zealand; General Paediatrics, Starship Children's Hospital, Auckland, New Zealand.
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Engan M, Hammer IJ, Bekken M, Halvorsen T, Fretheim-Kelly ZL, Vollsæter M, Bovim LPV, Røksund OD, Clemm H. Reliability of maximum oxygen uptake in cardiopulmonary exercise testing with continuous laryngoscopy. ERJ Open Res 2021; 7:00825-2020. [PMID: 33614778 PMCID: PMC7882785 DOI: 10.1183/23120541.00825-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 11/25/2020] [Indexed: 11/29/2022] Open
Abstract
Aims A cardiopulmonary exercise test (CPET) is the gold standard to evaluate symptom-limiting exercise intolerance, while continuous laryngoscopy performed during exercise (CLE) is required to diagnose exercise-induced laryngeal obstruction. Combining CPET with CLE would save time and resources; however, the CPET data may be distorted by the extra equipment. We therefore aimed to study whether CPET with CLE influences peak oxygen uptake (V′O2peak) and other gas exchange parameters when compared to a regular CPET. Methods Forty healthy athletes without exercise-related breathing problems, 15–35 years of age, performed CPET to peak exercise with and without an added CLE set-up, in randomised order 2–4 days apart, applying an identical computerised treadmill protocol. Results At peak exercise, the mean difference (95% confidence interval) between CPET with and without extra CLE set-up for V′O2peak, respiratory exchange ratio (RER), minute ventilation (V′E) and heart rate (HR) was 0.2 (−0.4 to 0.8) mL·kg−1·min−1, 0.01(−0.007 to 0.027) units, 2.6 (−1.3 to 6.5) L·min−1 and 1.4 (−0.8 to 3.5) beats·min−1, respectively. Agreement (95% limits of agreement) for V′O2peak, RER and V′E was 0.2 (±3.7) mL·kg−1·min−1, 0.01 (±0.10) units and 2.6 (±24.0) L·min−1, respectively. No systematic or proportional bias was found except for the completed distance, which was 49 m (95% CI 16 to 82 m) longer during CPET. Conclusion Parameters of gas exchange, including V′O2peak and RER, obtained from a maximal CPET performed with the extra CLE set-up can be used interchangeably with data obtained from standard CPET, thus preventing unnecessary additional testing. Cardiopulmonary exercise testing (CPET) with concurrent continuous laryngoscopy provides reliable measures for maximal oxygen consumption and other CPET datahttps://bit.ly/36wVJhb
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Affiliation(s)
- Mette Engan
- Dept of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Dept of Clinical Science, University of Bergen, Bergen, Norway.,These authors contributed equally
| | - Ida Jansrud Hammer
- Dept of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,These authors contributed equally
| | - Marianne Bekken
- Dept of Clinical Science, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Dept of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Dept of Clinical Science, University of Bergen, Bergen, Norway.,Dept of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Zoe Louise Fretheim-Kelly
- Dept of Clinical Science, University of Bergen, Bergen, Norway.,Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Oslo, Norway
| | - Maria Vollsæter
- Dept of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Dept of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Ola Drange Røksund
- Dept of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Hege Clemm
- Dept of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Dept of Clinical Science, University of Bergen, Bergen, Norway
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Vollsæter M, Stensrud T, Maat R, Halvorsen T, Røksund OD, Sandnes A, Clemm H. Exercise Related Respiratory Problems in the Young-Is It Exercise-Induced Bronchoconstriction or Laryngeal Obstruction? Front Pediatr 2021; 9:800073. [PMID: 35047465 PMCID: PMC8762363 DOI: 10.3389/fped.2021.800073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
Complaints of breathlessness during heavy exercise is common in children and adolescents, and represent expressions of a subjective feeling that may be difficult to verify and to link with specific diagnoses through objective tests. Exercise-induced asthma and exercise-induced laryngeal obstruction are two common medical causes of breathing difficulities in children and adolescents that can be challenging to distinguish between, based only on the complaints presented by patients. However, by applying a systematic clinical approach that includes rational use of tests, both conditions can usually be diagnosed reliably. In this invited mini-review, we suggest an approach we find feasible in our everyday clinical work.
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Affiliation(s)
- Maria Vollsæter
- Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Section for Paediatrics, University of Bergen, Bergen, Norway
| | - Trine Stensrud
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Robert Maat
- Department of Otorhinolaryngology, Saxenburgh Medical Center, Hardenberg, Netherlands
| | - Thomas Halvorsen
- Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Section for Paediatrics, University of Bergen, Bergen, Norway.,Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Ola Drange Røksund
- Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Faculty of Health and Social Sciences, Bergen University College, Bergen, Norway
| | - Astrid Sandnes
- Department of Internal Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - Hege Clemm
- Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Section for Paediatrics, University of Bergen, Bergen, Norway
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Daines L, Buekers J, Bolado BA, Kocks JW, Vagheggini G, Poberezhets V, Vogiatzis I, Pinnock H, Vanfleteren LE. ERS International Congress 2020: highlights from the General Pneumology Assembly. ERJ Open Res 2021; 7:00841-2020. [PMID: 33585656 PMCID: PMC7869601 DOI: 10.1183/23120541.00841-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/20/2020] [Indexed: 01/21/2023] Open
Abstract
The European Respiratory Society (ERS) accepted 4062 abstracts for presentation at the ERS International Congress in 2020. Although the conference was held virtually, making it possible to replay presentations, it remains a challenge to keep abreast of all the clinical and scientific advances. Therefore, this article provides highlights from the General Pneumology Assembly. Selected presentations from rehabilitation and chronic care, general practice and primary care, and electronic/mobile health (e-health/m-health) are summarised. The highlights incorporate novel findings from laboratory-based science, randomised controlled trials and qualitative research together with insights from newly available clinical guidelines.
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Affiliation(s)
- Luke Daines
- Allergy and Respiratory Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Joren Buekers
- ISGlobal, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
- Measure, Model and Manage Bioresponses (M3-BIORES), Dept of Biosystems, KU Leuven, Leuven, Belgium
| | | | - Janwillem W.H. Kocks
- General Practitioners Research Institute, Groningen, The Netherlands
- GRIAC Research Institute, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Observational and Pragmatic Research Institute, Singapore
| | - Guido Vagheggini
- Chronic Respiratory Failure Care Pathway, Dept of Medical Specialties, Azienda USL Toscana Nordovest, Pisa, Italy
- Fondazione Volterra Ricerche ONLUS, Volterra, Italy
| | - Vitalii Poberezhets
- Dept of Propedeutics of Internal Medicine, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
| | - Ioannis Vogiatzis
- Faculty of Health and Life Sciences, Northumbria University Newcastle, Newcastle upon Tyne, UK
| | - Hilary Pinnock
- Allergy and Respiratory Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Lowie E.G.W. Vanfleteren
- COPD Center, Dept of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Dept of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Wilhite DP, Bhammar DM, Balmain BN, Martinez-Fernandez T, Babb TG. Inhaled albuterol increases estimated ventilatory capacity in nonasthmatic children without and with obesity. Respir Physiol Neurobiol 2020; 285:103597. [PMID: 33301965 DOI: 10.1016/j.resp.2020.103597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/05/2020] [Accepted: 12/06/2020] [Indexed: 10/22/2022]
Abstract
Forced mid-expiratory flow (i.e., isoFEF25-75) may increase with a short-acting β2-agonist in nonasthmatic children without bronchodilator responsiveness. This could also increase estimated ventilatory capacity along mid-expiration (V̇Ecap25-75), especially in vulnerable children with obesity who exhibit altered breathing mechanics. We estimated V̇Ecap25-75 pre- and post-albuterol treatment in 8-12yo children without (n = 28) and with (n = 46) obesity. A two-way ANOVA was performed to determine effects of an inhaled bronchodilator (pre-post) and obesity (group) on isoFEF25-75 and V̇Ecap25-75. There was no group by bronchodilator interaction or main group effect on outcome variables. However, a significant main effect of the bronchodilator was detected in spirometry parameters, including a substantial increase in isoFEF25-75 (17.1 ± 18.0 %) and only a slight (non-clinical) but significant increase in FEV1 (2.4 ± 4.3 %). V̇Ecap25-75 significantly increased with albuterol (+11.7 ± 10.6 L/min; +15.8 ± 13.9 %). These findings imply potentially important increases in ventilatory reserve with a bronchodilator in nonasthmatic children without and with obesity, which could potentially influence respiratory function at rest and during exercise.
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Affiliation(s)
- Daniel P Wilhite
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and UT Southwestern Medical Center, Dallas, TX, United States
| | - Dharini M Bhammar
- Department of Kinesiology and Nutrition Sciences, University of Nevada-Las Vegas, Las Vegas, NV, United States
| | - Bryce N Balmain
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and UT Southwestern Medical Center, Dallas, TX, United States
| | | | - Tony G Babb
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and UT Southwestern Medical Center, Dallas, TX, United States.
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Difficult and Severe Asthma in Children. CHILDREN-BASEL 2020; 7:children7120286. [PMID: 33322016 PMCID: PMC7764801 DOI: 10.3390/children7120286] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 12/24/2022]
Abstract
Asthma is the most frequent chronic inflammatory disease of the lower airways affecting children, and it can still be considered a challenge for pediatricians. Although most asthmatic patients are symptom-free with standard treatments, a small percentage of them suffer from uncontrolled persistent asthma. In these children, a multidisciplinary systematic assessment, including comorbidities, treatment-related issues, environmental exposures, and psychosocial factors is needed. The identification of modifiable factors is important to differentiate children with difficult asthma from those with true severe therapy-resistant asthma. Early intervention on modifiable factors for children with difficult asthma allows for better control of asthma without the need for invasive investigation and further escalation of treatment. Otherwise, addressing a correct diagnosis of true severe therapy-resistant asthma avoids diagnostic and therapeutic delays, allowing patients to benefit from using new and advanced biological therapies.
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Morillo-Argudo DA, Andrade Tenesaca DS, Rodas-Espinoza CR, Perkin MR, Gebreegziabher TL, Zuñiga GA, Andrade Muñoz DD, Ramírez PL, García García AA, Ochoa-Avilés AM. Food allergy, airborne allergies, and allergic sensitisation among adolescents living in two disparate socioeconomic regions in Ecuador: A cross-sectional study. World Allergy Organ J 2020; 13:100478. [PMID: 33294112 PMCID: PMC7677699 DOI: 10.1016/j.waojou.2020.100478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/28/2020] [Accepted: 10/13/2020] [Indexed: 11/13/2022] Open
Abstract
Background Allergic diseases are under-investigated and overlooked health conditions in developing countries. We measured the prevalence of food allergy (FA), airborne allergic disease, and allergic sensitisation among adolescents living in 2 socio-demographically disparate regions in Ecuador. We investigated which risk factors are associated with these conditions. Methods A cross-sectional study involved 1338 students (mean age: 13 ± 0.9 years old) living in Cuenca (n = 876) and Santa Isabel (n = 462). History of allergic symptoms (noted by parents or doctor) to food, house dust mites (HDM), pollen, and pets were recorded. Sociodemographic characteristics, environmental exposures, and parental history of allergic disorders data were collected. Sensitisation to 19 food and 20 aeroallergens was measured by skin-prick testing (SPT). FA and airborne allergic diseases (to HDM, pollen, cat, or dog) were defined as a report of allergic symptoms noted by doctor, together with a positive SPT (wheal size ≥3 mm). Logistic regression models were used to identify environmental and parental factors associated with allergic conditions. Results FA was prevalent among 0.4% (95% CI 0.2%–0.9%), and food sensitisation among 19.1% of the adolescents. Shrimp was the most frequent food linked with FA and food sensitisation. Risk factors associated with FA could not be evaluated due to the low prevalence. Food sensitisation was higher among adolescents exposed to family smoking (OR 1.63, 95% CI 1.14–2.34, p = 0.008) and those with parental history of allergic disorders (OR 1.68, 95% CI 1.13–2.49, p = 0.01), but less common among adolescents owning dogs (OR 0.59, 95% CI 0.41–0.84, p = 0.003). Airborne allergic diseases were prevalent amongst 12.0% of the adolescents (95% CI: 10.4–13.9, n = 1321), with HDM as the primary allergen (11.2%). Airborne allergic diseases were less common among adolescents with more siblings (OR 0.79, 95% CI 0.65–0.96, p = 0.02) and those who lived with farm animals in the first year of life (OR 0.47, 95% CI 0.23–0.95, p = 0.04), but, most common among adolescents with a smoking family (OR 1.67, 95% CI 1.04–2.70, p = 0.03) and with a parental history of allergic disorders (OR self-perceived: 2.62, 95% CI 1.46–4.71, p = 0.001; OR diagnosed by a doctor: 4.07, 95% CI 2.44–6.80, p < 0.001). Conclusions FA and airborne allergies are less prevalent in Ecuador than in developed regions; there is a great dissociation between the prevalence of allergic disease and allergic sensitisation. Shrimp and HDM were the most prevalent allergens. Risk factors identified in this study to be related to allergic diseases should be considered by physicians, health practitioners, and epidemiologists in Ecuador.
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Affiliation(s)
- Diana A Morillo-Argudo
- Department of Biosciences, Faculty of Chemistry, University of Cuenca, Cuenca, Azuay, Ecuador
| | | | | | - Michael R Perkin
- Population Health Research Institute, St George's, University of London, Cranmer Terrace, London, SW17 0RE, England, United Kingdom
| | | | | | - Diana D Andrade Muñoz
- Department of Biosciences, Faculty of Chemistry, University of Cuenca, Cuenca, Azuay, Ecuador
| | - Patricia L Ramírez
- Department of Biosciences, Faculty of Chemistry, University of Cuenca, Cuenca, Azuay, Ecuador
| | - Ana A García García
- Department of Biosciences, Faculty of Chemistry, University of Cuenca, Cuenca, Azuay, Ecuador
| | - Angélica M Ochoa-Avilés
- Department of Biosciences, Faculty of Chemistry, University of Cuenca, Cuenca, Azuay, Ecuador
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Biernikiewicz M, Germain N, Toumi M. Second opinions, multiple physician appointments, and overlapping prescriptions in the paediatric population: A systematic literature review. J Eval Clin Pract 2020; 26:1761-1767. [PMID: 32003511 DOI: 10.1111/jep.13365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/16/2020] [Accepted: 01/16/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Doctor shopping, double doctoring, and overlapping prescriptions are often used as synonyms for multiple physician appointments in the same disease episode. Such behaviours translate into poor patient satisfaction and patient-doctor communication as well as abuse or misuse of drugs, increasing health care costs and resulting in negative health consequences. This systematic review of the literature was conducted to identify factors that drive doctor-shopping behaviour in children's caregivers. METHODS The search was conducted in PubMed and grey literature and was based on the following search terms: included doctor or physician shopping, drug seeking, double doctoring, children, and combinations of those. Overall, 500 records were identified, of which 11 were selected for qualitative synthesis. Data extracted considered definitions of doctor shopping, co-morbidities, and target population characteristics. RESULTS Definitions of doctor shopping were inconsistent. The frequency of doctor shopping was high for acute illnesses and ranged from 53% in children with a fever in Hong Kong to 18% at an emergency department in Canada. The incidence of this phenomenon was low when taking into account addictive drugs and was rated at 0.02% to 0.3% in the full paediatric population. This phenomenon was more prevalent in children younger than 1 year, in children with attention-deficit hyperactivity disorder (ADHD) and co-morbid psychiatric conditions, and in those whose caregivers themselves had psychiatric conditions. It was more frequent in cases with an acute disease (eg, fever, gastroenteritis, and urinary tract infection) than a chronic disease (eg, asthma). CONCLUSIONS The knowledge about doctor shopping by children's caregivers is limited, despite that this is a frequent behaviour. There is a need for further research covering a broader range of diseases. The causes and consequences of doctor shopping should be sought as well to investigate its relation to health care regulations and possibility to reduce unnecessary medical resource utilization.
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Affiliation(s)
| | - Nicola Germain
- Health Economics and Outcomes Research, Creativ-Ceutical, Paris, France
| | - Mondher Toumi
- Public Health Department, Aix-Marseille University, Marseilles, France
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de Jong CCM, Pedersen ESL, Mozun R, Müller-Suter D, Jochmann A, Singer F, Casaulta C, Regamey N, Moeller A, Ardura-Garcia C, Kuehni CE. Diagnosis of asthma in children: findings from the Swiss Paediatric Airway Cohort. Eur Respir J 2020; 56:13993003.00132-2020. [PMID: 32499334 DOI: 10.1183/13993003.00132-2020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/26/2020] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Diagnosing asthma in children remains a challenge because respiratory symptoms are not specific and vary over time. AIM In a real-life observational study, we assessed the diagnostic accuracy of respiratory symptoms, objective tests and two paediatric diagnostic algorithms (proposed by the Global Initiative for Asthma (GINA) and the National Institute for Health and Care Excellence (NICE)) in the diagnosis of asthma in school-aged children. METHODS We studied children aged 5-17 years who were referred consecutively to pulmonary outpatient clinics for evaluation of suspected asthma. Symptoms were assessed by parental questionnaire. The investigations included specific IgE measurement or skin prick tests, measurement of exhaled nitric oxide fraction (F eNO), spirometry, body plethysmography and bronchodilator reversibility (BDR). Asthma was diagnosed by paediatric pulmonologists based on all available data. We assessed diagnostic accuracy of symptoms, tests and diagnostic algorithms by calculating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the curve (AUC). RESULTS Among 514 participants, 357 (70%) were diagnosed with asthma. The combined sensitivity and specificity was highest for any wheeze (sensitivity=75%, specificity=65%), dyspnoea (sensitivity=56%, specificity=76%) and wheeze triggered by colds (sensitivity=58%, specificity=78%) or by exercise (sensitivity=55%, specificity=74%). Of the diagnostic tests, the AUC was highest for specific total airway resistance (sRtot; AUC=0.73) and lowest for the residual volume (RV)/total lung capacity (TLC) ratio (AUC=0.56). The NICE algorithm had sensitivity=69% and specificity=67%, whereas the GINA algorithm had sensitivity=42% and specificity=90%. CONCLUSION This study confirms the limited usefulness of single tests and existing algorithms for the diagnosis of asthma. It highlights the need for new and more appropriate evidence-based guidance.
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Affiliation(s)
- Carmen C M de Jong
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Eva S L Pedersen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Rebeca Mozun
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Anja Jochmann
- Paediatric Respiratory Medicine, University Children's Hospital (UKBB), University of Basel, Basel, Switzerland
| | - Florian Singer
- Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland.,PedNet Bern, Children's University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Carmen Casaulta
- Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland.,Paediatric Respiratory Medicine, Kantonsspital Graubunden, Chur, Switzerland
| | - Nicolas Regamey
- Division of Paediatric Pulmonology, Children's Hospital, Lucerne, Switzerland
| | - Alexander Moeller
- Division of Paediatric Pulmonology, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | | | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland
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Spirometry and FeNO testing for asthma in children in UK primary care: a prospective observational cohort study of feasibility and acceptability. Br J Gen Pract 2020; 70:e809-e816. [PMID: 33077507 DOI: 10.3399/bjgp20x713033] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/13/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The National Institute for Health and Care Excellence recommends the use of spirometry and measuring the fraction of exhaled nitric oxide (FeNO) as part of the diagnostic work-up for children with suspected asthma, and spirometry for asthma monitoring, across all care settings. However, the feasibility and acceptability of these tests within primary care are not known. AIM To investigate the feasibility, acceptability, training, and capacity requirements of performing spirometry and FeNO testing in children managed for asthma in UK primary care. DESIGN AND SETTING Prospective observational study involving 10 general practices in the East Midlands, UK, and 612 children between 2016 and 2017. METHOD Training and support to perform spirometry and FeNO in children aged 5 to 16 years were provided to participating practices. Children on the practice's asthma registers, and those with suspected asthma, were invited for a routine asthma review. Time for general practice staff to achieve competencies in performing and/or interpreting both tests, time to perform the tests, number of children able to perform the tests, and feedback on acceptability were recorded. RESULTS A total of 27 general practice staff were trained in a mean time of 10.3 (standard deviation 2.7) hours. Usable spirometry and FeNO results were obtained in 575 (94%) and 472 (77%) children respectively. Spirometry is achievable in the majority of children aged ≥5 years, and FeNO in children aged ≥7 years. All of the staff and 97% of families surveyed provided positive feedback for the tests. CONCLUSION After training, general practice staff obtained quality spirometry and FeNO data from most children tested. Testing was acceptable to staff and families. The majority of general practice staff reported that spirometry helped them to manage children's asthma better.
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