From MASK-air and SILAM to CATALYSE (Climate Action To Advance HeaLthY Societies in Europe)

Plant species vary under different climatic conditions and the distribution of pollen in the air. Trends in pollen distribution can be used to assess the impact of climate change on public health. In 2015, the Mobile Airways Sentinel networK for rhinitis and asthma (MASK-air®) was launched as a project of the European Innovation Partnership on Active and Healthy Ageing (EIP-on-AHA, DG Santé and DG CONNECT). This project aimed to develop a warning system to inform patients about the onset of the pollen season, namely, the System for Integrated modeLling of Atmospheric coMposition (SILAM). A global-to-meso-scale dispersion model was developed by the Finnish Meteorological Institute (FMI). It provides quantitative information on atmospheric pollution of anthropogenic and natural origins, particularly on allergenic pollens. Impact of Air Pollution on Asthma and Rhinitis (POLLAR, EIT Health) has combined MASK-air clinical data with SILAM forecasts. A new Horizon Europe grant (Climate Action to Advance HeaLthY Societies in Europe [CATALYSE]; grant agreement number 101057131), which came into force in September 2022, aims to improve our understanding of climate change and help us find ways to counteractit. One objective of this project is to develop early warning systems and predictive models to improve the effectiveness of strategies for adapting to climate change. One of the warning systems is focused on allergic rhinitis (CATALYSE Task 3.2), with a collaboration between the FMI (Finland), Porto University (Portugal), MASK-air SAS (France), ISGlobal (Spain), Hertie School (Germany), and the University of Zurich (Switzerland). It is to be implemented with the support of the European Academy of Allergy and Clinical Immunology. This paper reports the planning of CATALYSE Task 3.2.

Adherence to inhaled corticosteroids and long-acting β2-agonists in asthma: A MASK-air study

INTRODUCTION

Adherence to controller medication is a major problem in asthma management, being difficult to assess and tackle. mHealth apps can be used to assess adherence. We aimed to assess the adherence to inhaled corticosteroids+long-acting β2-agonists (ICS+LABA) in users of the MASK-air® app, comparing the adherence to ICS+formoterol (ICS+F) with that to ICS+other LABA.

MATERIALS AND METHODS

We analysed complete weeks of MASK-air® data (2015-2022; 27 countries) from patients with self-reported asthma and ICS+LABA use. We compared patients reporting ICS+F versus ICS+other LABA on adherence levels, symptoms and symptom-medication scores. We built regression models to assess whether adherence to ICS+LABA was associated with asthma control or short-acting beta-agonist (SABA) use. Sensitivity analyses were performed considering the weeks with no more than one missing day.

RESULTS

In 2598 ICS+LABA users, 621 (23.9%) reported 4824 complete weeks and 866 (33.3%) reported weeks with at most one missing day. Higher adherence (use of medication ≥80% of weekly days) was observed for ICS+other LABA (75.1%) when compared to ICS+F (59.3%), despite both groups displaying similar asthma control and work productivity. The ICS+other LABA group was associated with more days of SABA use than the ICS+F group (median=71.4% versus 57.1% days). Each additional weekly day of ICS+F use was associated with a 4.1% less risk in weekly SABA use (95%CI=-6.5;-1.6%;p=0.001). For ICS+other LABA, the percentage was 8.2 (95%CI=-11.6;-5.0%;p<0.001).

CONCLUSIONS

In asthma patients adherent to the MASK-air app, adherence to ICS+LABA was high. ICS+F users reported lower adherence but also a lower SABA use and a similar level of control.

Biologicals in severe chronic rhinosinusitis with nasal polyps: translation to clinical practice while waiting for head-to-head studies

Chronic rhinosinusitis with nasal polyps (CRSwNP) affects 1.0-2.6% of the population (1) and results in relevant direct and indirect costs. Recently, several randomized controlled trials (RCTs) with Type 2-targeting biologicals (anti-IL4Rα, anti-IL5R, anti-IL5 and anti-IgE) opened a new treatment field for patients refractory to first-line treatments (2,3).

Patients with laboratory criteria of anti-phospholipid syndrome and 'non-criteria' manifestations: a multicenter cohort

OBJECTIVES

Patients with laboratory criteria for anti-phospholipid syndrome (APS) but presenting only 'non-criteria' clinical manifestations are scarcely characterized in the literature. We aimed to analyse a cohort of these patients regarding the most prevalent manifestations, antibody profile, and treatments, while establishing a comparison with definite APS patients.

METHOD

A retrospective analysis was conducted of individuals fulfilling APS laboratory criteria assessed in two tertiary European hospitals between 2005 and 2020. Patients without clinical criteria but with non-criteria manifestations (termed 'clinical non-criteria') and age-/gender-matched controls were included.

RESULTS

Altogether, 75 clinical non-criteria patients were analysed, with haematological (thrombocytopenia, haemolytic anaemia) and 'mild' neurological manifestations (white-matter lesions, migraine) as the most prevalent non-obstetric involvements. These patients displayed more thrombocytopenia [odds ratio (OR) = 3.6, 95% confidence interval (CI) 1.7-7.6; p = 0.001] than controls with APS, but severe manifestations, such as valvular heart disease (p < 0.001), livedoid vasculopathy, seizures, chorea, transverse myelitis, bone necrosis, and alveolar haemorrhage, occurred only in definite APS patients. Corticosteroids were required by 40% of patients with thrombocytopenia. Manifestations in anticoagulated patients included white-matter lesions, nephropathy, superficial vein thrombosis, amaurosis fugax, and livedoid vasculopathy. Suspicion of progression towards systemic lupus erythematosus (SLE) occurred in 19% of non-SLE individuals.

CONCLUSION

'Clinical non-criteria' patients displayed significant treatment use, predominantly haematological involvement, and less severe manifestations than definite APS controls. Some patients may additionally progress to future SLE. The impact of certain manifestations flags them as potential future contributors to classifying individuals as definite APS.

Rhinitis associated with asthma is distinct from rhinitis alone: The ARIA-MeDALL hypothesis

Asthma, rhinitis and atopic dermatitis (AD) are interrelated clinical phenotypes that partly overlap in the human interactome. The concept of "one-airway-one-disease", coined over 20 years ago, is a simplistic approach of the links between upper- and lower-airway allergic diseases. With new data, it is time to reassess the concept. This article reviews (i) the clinical observations that led to Allergic Rhinitis and its Impact on Asthma (ARIA), (ii) new insights into polysensitisation and multimorbidity, (iii) advances in mHealth for novel phenotype definition, (iv) confirmation in canonical epidemiologic studies, (v) genomic findings, (vi) treatment approaches and (vii) novel concepts on the onset of rhinitis and multimorbidity. One recent concept, bringing together upper- and lower-airway allergic diseases with skin, gut and neuropsychiatric multimorbidities, is the "Epithelial Barrier Hypothesis". This review determined that the "one-airway-one-disease" concept does not always hold true and that several phenotypes of disease can be defined. These phenotypes include an extreme "allergic" (asthma) phenotype combining asthma, rhinitis and conjunctivitis. Rhinitis alone and rhinitis and asthma multimorbidity represent two distinct diseases with the following differences: (i) genomic and transcriptomic background (Toll-Like Receptors and IL-17 for rhinitis alone as a local disease; IL-33 and IL-5 for allergic and non-allergic multimorbidity as a systemic disease), (ii) allergen sensitisation patterns (mono- or pauci-sensitisation versus polysensitisation), (iii) severity of symptoms and (iv) treatment response. In conclusion, rhinitis alone (local disease) and rhinitis with asthma multimorbidity (systemic disease) should be considered as two distinct diseases, possibly modulated by the microbiome, and may be a model for understanding the epidemics of chronic and auto-immune diseases.

Anxiety and depression risk in patients with allergic rhinitis: a systematic review and meta-analysis

BACKGROUND

Allergic diseases appear to be associated with mood disorders. However, particularly regarding allergic rhinitis (AR), such association has not been adequately systematically reviewed. Therefore, we conducted a systematic review and meta-analysis to quantify the association between AR and depression and anxiety.

METHODOLOGY

We performed an electronic search of PubMed, Web of Science and Scopus for observational studies assessing the association between AR and depression and anxiety. Such association was quantified by means of random-effects meta-analysis, with estimation of pooled odds ratio (OR). Sources of heterogeneity were explored by subgroup analysis.

RESULTS

We included a total of 24 primary studies, of which 23 assessed depression and 11 assessed anxiety. Of these, 12 studies presented OR from multivariable regression models and were included in our meta-analysis. AR was associated with higher odds of depression and anxiety.

CONCLUSIONS

AR appears to be associated with high risk of depression and anxiety. While our results point to the importance of mental comorbidities among patients with AR, longitudinal studies are needed adopting uniform definitions and presenting results stratified by AR severity.

AB0340 PATIENTS WITH LABORATORY CRITERIA OF ANTIPHOSPHOLIPID SYNDROME AND “NON-CRITERIA” MANIFESTATIONS: A MULTICENTER STUDY

Background:

Patients with laboratory criteria for antiphospholipid syndrome (APS) and presenting only “non-criteria” clinical manifestations are scarcely described in the literature [1-3].

Objectives:

To describe a cohort of these patients, portraying potential associations between “non-criteria” manifestations, antiphospholipid antibodies (aPL) and treatments.

Methods:

Retrospective analysis of patients with aPL positivity fulfilling APS criteria assessed in two tertiary European hospitals between 2005 and 2020. Those without criteria clinical manifestations but with the presence of “non-criteria” manifestations were included.

Results:

A total of 75 patients were analyzed. The predominant non-obstetric involvements were hematologic (thrombocytopenia, hemolytic anemia) and “mild” neurological (white matter lesions, migraine), with an absence or near absence of cutaneous, cardiac, pulmonary and more severe neurologic manifestations (Table 1). In obstetric morbidity, two spontaneous abortions before 10 weeks and infertility were the more frequent manifestations. LA positivity was positively associated with non-obstetric manifestations (OR=4.2, 95% CI 1.5-11.9; p=0.007) while an aCL profile was associated with obstetric manifestations (OR 7.0, 95% CI 2.3-21.3; p=0.001). A suspicion of progression towards SLE was considered plausible in 13 (19%) of non-SLE individuals. Twelve (40.0%) of patients with thrombocytopenia as their only hematological involvement required corticosteroids. History of infertility (OR 6.1, 95% CI 1.3-28; p=0.02) and IVF recurrent failure (OR 6.5, 95% CI 1.2-36.3; p=0.032) were associated with pregnancy treatment with LMWH/LDA combination. Among patients under anticoagulation, clinical manifestations included brain white matter lesions, APS nephropathy, superficial vein thrombosis, amaurosis fugax, and livedoid vasculopathy. A higher value of GAPSS was observed in patients with non-obstetric (median 9, IQR 5-13) in comparison to those with obstetric manifestations (median 5, IQR 4-5.5).

Conclusion:

The present article stresses the clinical relevance of these patients, with an impression that at least some manifestations will contribute in the future to the classification of individuals as definite APS.

References:

[1]J. Alijotas-Reig et al., Comparative study of obstetric antiphospholipid syndrome (OAPS) and non-criteria obstetric APS (NC-OAPS): report of 1640 cases from the EUROAPS registry. Rheumatology (Oxford), (2019).

[2]M. Fredi et al., Risk Factors for Adverse Maternal and Fetal Outcomes in Women With Confirmed aPL Positivity: Results From a Multicenter Study of 283 Pregnancies. Front Immunol9, 864 (2018).

[3]E. Sevim et al., Characteristics of Antiphospholipid Antibody Positive Patients in AntiPhospholipid Syndrome Alliance for Clinical Trials and InternatiOnal Networking. Arthritis Care & Researchn/a.

Table 1.

“Non-criteria” clinical manifestations present in the analyzed population.

Clinical manifestationn (%)Non-obstetricn = 49Thrombocytopenia34 (69.4)Coombs´ positivity11 (22.4)Migraine11 (22.4)Hemolytic anemia5 (10.2)Brain MRI white matter lesions5 (10.4)Raynaud´s phenomenon5 (10.2)Superficial vein thrombosis4 (8.1)Evans syndrome4 (8.1)Amaurosis fugax3 (6.1)APS nephropathy2 (4.1)Livedo reticularis1 (2.0)Livedoid vasculopathy1 (2.0)Memory lapses1 (2.0)Pseudo-multiple sclerosis1 (2.0)Sensorineural hearing loss1 (2.0)Splinter hemorrhages1 (2.0)Obstetricn = 38Two spontaneous abortions <10 weeks16 (42.1)Infertility14 (36.8)≥ 2 or more IVF failures11 (28.9)Late IUGR (>34 weeks)7 (18.4)Premature birth between 34 and 37 weeks7 (18.4)Placental ischemia5 (13.1)Late preeclampsia (>34 weeks)3 (8.0)Placental abruption2 (5.3)Placental hematoma2 (5.3)

Abbreviations –aCL: anticardiolipin antibodies; AI: Autoimmune; AID: Autoimmune disease; aPL: Antiphospholipid antibodies; IUGR: Intrauterine growth restriction; IVF: in vitro fertilization; LA: Lupus anticoagulant.

Disclosure of Interests:

None declared

POS0767 CLINICAL MANIFESTATIONS, TREATMENT, AND OUTCOMES OF “NON-CRITERIA” ANTIPHOSPHOLIPID SYNDROME IN COMPARISON WITH DEFINITE ANTIPHOSPHOLIPID SYNDROME: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background:

Patients with laboratorial or clinical manifestations suggestive of antiphospholipid syndrome (APS) but not fulfilling the classification criteria [1] constitute a challenge in clinical practice.

Objectives:

To establish a comparison between patients with “non-criteria” versus those with definite APS on the frequency of clinical manifestations, prescribed therapies and reported outcomes.

Methods:

A systematic review of observational studies comparing “non-criteria” with definite APS patients was performed searching 4 electronic databases. Data was extracted on clinical manifestations, therapies and outcomes. Studies were analyzed globally and, where possible, grouped under four potential “non-criteria” APS subsets. Random-effects meta-analyses were performed.

Results:

Fourteen studies were included, assessing a total of 3,238 participants (Table 1). In the meta-analysis, no difference was detected in the frequency of arterial events or thrombosis recurrence between “non-criteria” and definite APS. However, a lower frequency of venous events was observed in “non-criteria” patients (risk ratio [RR]=0.9; 95%CI 0.7-1.0; p-value=0.047, I2=0%; Q Cochran p-value=0.226). Regarding obstetric morbidity, no difference was observed in most outcomes, but previous history of intrauterine growth restriction was less frequent (RR=0.7; 95%CI=0.6-0.9; p-value=0.003, I2=0%; Q Cochran p-value=0.228) and the risk of prematurity in followed pregnancies lower in “non-criteria” patients. There was no significant difference in treatment frequency between groups, except for less use of hydroxychloroquine in “non-criteria” APS (RR=0.7; 95%CI=0.5-0.9; p-value=0.007, I2=46.5%; Q Cochran p-value=0.642). There was no significant difference in the risk of fetal loss between groups either with or without treatment (Figure 1). It should be noted that significant heterogeneity was observed in some outcomes across the studied categories. Most studies focused on “seronegative” and “incomplete laboratory” APS.

Table 1.

Description of studies included in the systematic review.

Author, year (reference)Number of PatientsDefinite APSNC-APS(global)Mekinian, 2012 [2]2553Rodriguez-Garcia, 2012 [3]8767Conti, 2014 [4]2524Ofer-Shiber, 2015 [5]126117Mekinian, 2016 [6]8396Omar, 2018 [7]3030Signorelli, 2017 [8]7713Fredi, 2018 [9]8581Litvinova, 2018 [10]4117Alijotas-Reig, 2019 [11]1000640Ferreira, 2020 [12]1521Liu, 2020 [13]19290Li, 2020 [14]3494Lo, 2020 [15]1224

Abbreviations – APS: Antiphospholipid Syndrome; NC-APS: Non-criteria antiphospholipid syndrome.

Conclusion:

This review suggests an absence of marked differences in most of the evaluated variables regarding clinical manifestations, treatment and outcomes between “non-criteria” and definite APS. These results should be interpreted with caution in light of the low-quality evidence available and heterogeneity observed in some outcomes.

References:

[1]S Miyakis et al., J Thromb Haemost 4 (2), 295 (2006).

[2]A Mekinian et al., Journal of Reproductive Immunology 94 (2), 222 (2012).

[3]JL Rodriguez-Garcia et al., Ann Rheum Dis 71 (2), 242 (2012).

[4]F Conti et al., J Immunol Res 2014, 389601 (2014).

[5]S Ofer-Shiber and Y Molad, Blood Coagul Fibrinolysis 26 (3), 261 (2015).

[6]A Mekinian et al., Semin Arthritis Rheum 46 (2), 232 (2016).

[7]G Omar et al., Egyptian Rheumatologist 40 (2), 111 (2018).

[8]F Signorelli et al., Annals of the Rheumatic Diseases 76, 887 (2017).

[9]M Fredi et al., Front Immunol 9, 864 (2018).

[10]E Litvinova et al., Front Immunol 9, 2971 (2018).

[11]J Alijotas-Reig et al., Rheumatology (Oxford) (2019).

[12]TG Ferreira et al., Clin Rheumatol 39 (4), 1167 (2020).

[13]T Liu et al., Arthritis Res Ther 22 (1), 33 (2020).

[14]X Li et al., Clinical Rheumatology (2020).

[15]HW Lo et al., Eur J Obstet Gynecol Reprod Biol 244, 205 (2020).

Figure 1.

Forest plot of studies included in the meta-analysis regarding pregnancy and treatment outcomes.

Acknowledgements:

The authors wish to thank Helena Donato, from the Documentation Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, for her assistance performing the search for the systematic review.

Disclosure of Interests:

None declared

Oral health effects of botulinum toxin treatment for drooling: a systematic review

Background

Drooling is a major morbidity in several neurological diseases. Intraglandular botulinum neurotoxin (BoNT) injections have been used to manage this condition. However, by decreasing salivary flow, BoNT injections may result in an increased risk of caries and other oral adverse effects. In this study, we aimed to assess whether, in patients with drooling, intraglandular BoNT injections are associated with increased dental caries development, modifications on salivary composition (oral pH, buffering capacity and osmolality) and cariogenic bacterial load.

Material and Methods

We performed a systematic review, searching PubMed, CENTRAL, Web of Science, and Scopus for all experimental and observational studies reporting on adverse effects of intraglandular BoNT injections in patients with drooling. Primary study selection, quality assessment, and data extraction were independently performed by two researchers. No studies were excluded based on their language, publication status or date of publication. Studies’ quality was based on revised Cochrane Risk of Bias tools. Meta-analysis was not performed.

Results

We retrieved 1025 studies, of which 5 were included. Two studies were two randomized controlled trials and three quasi-experimental studies. None of the included studies found BoNT injections to be associated with dental caries development or with significant reductions in oral pH. One of the included primary studies even observed an increase in salivary buffer capacity. One study found an increase in Lactobacilli counts. As for the risk of bias, two studies were classified as having a critical risk, two as high risk and one as having some concerns.

Conclusions

Currently, there is no evidence that, in patients with drooling, BoNT injections associate with increased risk of dental caries or disturbances in oral pH or salivary buffering capacity. However, the included primary studies had important limitations and differences in their methodologies.

Key words:Neurological diseases, drooling, sialorrhea, botulinum toxin, oral health, caries, saliva.

Cardiac surgery in infective endocarditis and predictors of in-hospital mortality

INTRODUCTION

Infective endocarditis (IE) is a serious disease with significant in-hospital mortality (15-30%) despite advances in medical and surgical therapy.

AIMS

To perform a clinical characterization of patients undergoing cardiac surgery for IE and to identify factors that predict in-hospital mortality.

METHODS

We retrospectively analyzed 145 patients with IE admitted between January 2006 and October 2017.

RESULTS

The median age was 72 years. IE was acquired mainly in the community (69%), and involved the native aortic valve in 54% of patients, biological prosthetic valves in 22.1% and mechanical valves in 10.3%. Staphylococcus spp. (31.0%) were the most frequent etiological agents. Cardiac surgery was emergent in 29 patients, urgent in 108, and elective in eight. The main indications were heart failure (57.9%), large vegetations (20%), systemic embolism (17.2%) and valve dysfunction (15.2%). Overall, biological valves were implanted in 62.1% of patients and mechanical valves in 37.2%. A total of 19 patients (13.1%) died. Predictors of mortality were preoperative atrial fibrillation and lower left ventricular ejection fraction, postoperative severe valve regurgitation associated with cardiogenic shock, sepsis, septic shock associated with cardiogenic shock, cardiac tamponade, need for renal replacement therapy and, although without statistical significance, emergent surgery.

CONCLUSIONS

There is a need for better indicators to enable early identification of surgical candidates for IE, implementation of a heart team, and better surgical strategies, including more rapid intervention, more specific postoperative care, and optimal antibiotic therapy.

Skin cancer healthcare impact: A nation-wide assessment of an administrative database

BACKGROUND

Skin cancer is an important health concern, with an increasing incidence worldwide.

OBJECTIVE

To assess the clinical and economic burden of melanoma (MM) and non-melanoma skin cancer (NMSC) at public hospitals in mainland Portugal.

METHODS

We used an administrative database containing a registration of all hospitalizations and ambulatory episodes occurred in Portuguese public hospitals between 2011 and 2015. We assessed all episodes with associated diagnoses of MM or NMSC regarding neoplasm location, metastases occurrence, length of stay, in-hospital mortality and hospital costs.

RESULTS

We assessed 15,913 MM and 72,602 NMSC episodes. 14.3% of MM episodes presented with metastases, compared to 1.9% of NMSC episodes. Patients' median age was lower for MM (66 years) than NMSC (76 years). The trunk was the most common location for MM (32.5%), followed by the lower limbs (26.5%). NMSC presented with higher length of stay than MM (median 5 versus 4 days; p < 0.001), but with lower in-hospital mortality (7.3% versus 11.9%; p < 0.001). MM episodes had higher average hospital costs than NMSC episodes (1197.7 versus 1113.5 €; p < 0.001). Overall, NMSC episodes amounted a total of 80.8 million € in hospital costs versus 19.1 million € for MM episodes.

CONCLUSION

Skin neoplasms have substantial impact on healthcare services. NMSC is an important contributor to this burden. NMSC underreporting should be tackled and it should not be downplayed in skin cancer preventative strategies.

Single dose versus multiple dose of antibiotic prophylaxis in caesarean section: a systematic review and meta-analysis

BACKGROUND

Prophylactic antibiotics are traditionally given as a single dose for caesarean section. However, inconsistent application of recommendations and recent evidence prompted a literature review.

OBJECTIVES

To assess the optimal regimen for antibiotic prophylaxis in caesarean section by comparing single versus multiple doses of the same intervention.

SEARCH STRATEGY

MEDLINE, Web of Knowledge, SCOPUS, CENTRAL and ongoing trials databases were searched. Reference lists were reviewed and international groups contacted.

SELECTION CRITERIA

Randomised controlled trials (RCT) comparing single with multiple dose regimens of the same antibiotic prophylaxis. Quasi-RCT and abstracts were suitable for inclusion.

DATA COLLECTION AND ANALYSIS

Reviewers independently extracted data and assessed quality of evidence. A random-effects model was used and results presented as risk ratio (RR) with 95% confidence intervals (CI).

MAIN RESULTS

Sixteen studies were included, involving 2695 women. Nonsignificant differences were observed between single dose and multiple dose antibiotic prophylaxis in the incidence of postpartum infectious morbidity (RR 0.95, 95% CI 0.75-1.20, I2 = 25%), endometritis (RR 1.03, 95% CI 0.74-1.42, I2 = 0%) and wound infection (RR 1.22, 95% CI 0.72-2.08, I2 = 0%). A trend towards lower risk of urinary tract infection was seen with multiple dose (RR 0.65, 95% CI 0.34-1.24, I2 = 0%).

CONCLUSIONS

There was insufficient evidence to determine whether there is a difference between single and multiple dose regimens in reducing the incidence of infectious morbidity after caesarean section. The quality of evidence was very low and well-designed RCTs are needed.

TWEETABLE ABSTRACT

Insufficient evidence of difference between dosage regimens of antibiotic prophylaxis in caesarean section.