Interferon β-1a ring prophylaxis to reduce household transmission of SARS-CoV-2: a cluster randomised clinical trial

Background

Accumulating evidence indicates that an early, robust type 1 interferon (IFN) response to SARS-CoV-2 is important in determining COVID-19 outcomes, with an inadequate IFN response associated with disease severity. Our objective was to examine the prophylactic potential of IFN administration to limit viral transmission.

Methods

A cluster randomised open label clinical trial was undertaken to determine the effects of pegylated IFNβ-1a administration on SARS-CoV-2 household transmission between December 3rd, 2020 and June 29th, 2021. Index cases were identified from databases of confirmed SARS-CoV-2 individuals in Santiago, Chile. Households were cluster randomised (stratified by household size and age of index cases) to receive 3 doses of 125 μg subcutaneous pegylated IFNβ-1a (172 households, 607 participants), or standard care (169 households, 565 participants). The statistical team was blinded to treatment assignment until the analysis plan was finalised. Analyses were undertaken to determine effects of treatment on viral shedding and viral transmission. Safety analyses included incidence and severity of adverse events in all treatment eligible participants in the standard care arm, or in the treatment arm with at least one dose administered. Clinicaltrials.gov identifier: NCT04552379.

Findings

5154 index cases were assessed for eligibility, 1372 index cases invited to participate, and 341 index cases and their household contacts (n = 831) enrolled. 1172 participants in 341 households underwent randomisation, with 607 assigned to receive IFNβ-1a and 565 to standard care. Based on intention to treat (ITT) and per protocol (PP) analyses for the primary endpoints, IFNβ-1a treatment did not affect duration of viral shedding in index cases (absolute risk reduction = -0.2%, 95% CI = -8.46% to 8.06%) and transmission of SARS-CoV-2 to household contacts (absolute risk reduction = 3.87%, 95% CI = -3.6% to 11.3%). Treatment with IFNβ-1a resulted in significantly more treatment-related adverse events, but no increase in overall adverse events or serious adverse events.

Interpretation

Based upon the primary analyses, IFNβ-1a treatment did not affect duration of viral shedding or the probability of SARS-CoV-2 transmission to uninfected contacts within a household.

Funding

Biogen PTY Ltd. Supply of interferon as 'Plegridy (peginterferon beta-1a).' The study was substantially funded by BHP Holdings Pty Ltd.

Maternal Obesity Is Associated With Higher Cord Blood Adipokines in Offspring Most Notably in Females

BACKGROUND

Deleterious long-term effects in the offspring from women with pregravid obesity have been described; however, the evidence supporting early metabolic and inflammatory markers in the offspring at birth and gender differences are conflicting.

OBJECTIVE

The present study aimed to compare cord blood adipokines and cytokines concentrations and anthropometric characteristics of the offspring of women with maternal obesity (MO) and normal-weight mothers (NWM). Also, maternal and neonatal variables on the association of maternal body mass index (BMI) with cord blood adipokines were evaluated.

METHODS

A cross-sectional analysis of a subsample of mother-child dyads participating in a cohort study (n = 221) was assessed. Anthropometrics, cord blood adipokines (leptin and adiponectin) and cytokines (interleukin [IL]-1β, IL-4, IL-10, IL-12 p40, IL-12p70, IL-13, and tumor necrosis factor α) concentrations in the offspring of normal-weight women (BMI >18.5 and <24.9 kg/m2) and women with pregravid obesity (BMI > 30 kg/m2) without comorbidities was performed.

RESULTS

Offspring from mothers with obesity had higher birth weight, a higher proportion of large for gestational age, higher ponderal index, and heavier placentae than offspring from normal-weight mothers (P < 0.05). Within the offspring from women with obesity, males had significantly higher weight, length, the proportion of large-for-gestational-age newborns, higher weight for length ratio. Males had more efficient placentas than females (P < 0.05). Higher adiponectin and leptin in both sexes and higher leptin in female offspring of mothers with obesity after adjusting for birth size (P < 0.05) were found. Higher IL-12p40 in the offspring of women with MO with no other differences in other cytokines among groups were evidenced.

CONCLUSIONS

Maternal obesity associates with a higher concentration of adiponectin and leptin in their offspring at birth. There is a relevant effect on anthropometrics in male offspring and on leptin in female newborn. Further studies need to evaluate the extension of these effects in postnatal life.

TRAIL IDENTIFICATION NUMBER

NCT02903134.

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

INTRODUCTION AND OBJECTIVES

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Serum periostin is not related to asthma predictive index

BACKGROUND

In contrast to adult asthmatic patients, studies on the role of serum periostin levels in schoolchildren with asthma are still conflictive, and very few studies have been performed in pre-schoolers. The aim of this study was to compare serum periostin levels in recurrent wheezer pre-schoolers according to their asthma predictive index (API) condition.

METHODS

We performed a case-control study enrolling pre-schoolers with recurrent wheezing episodes (>3 episodes confirmed by physician) presented at one paediatric clinic in Santiago, Chile. The population was divided according to stringent API criteria into positive or negative.

RESULTS

In a one-year period, 60 pre-schoolers were enrolled. After excluding 12 (due to not fulfilment of inclusion criteria or refusal of blood sample extraction), 48 remaining pre-schoolers (27 males, age range from 24 to 71 months) completed the study; 34 were API positive and 14 were API negative. There were no significant differences in demographics between groups. The level of serum periostin levels for pre-schoolers with positive API and negative API were (median 46.7 [25.5-83.1] and 67.5 [20.5-131.8], p=0.9, respectively). The area under the curve for the serum periostin levels for predict positive API was 0.5, 95% CI [0.29-0.70], p=0.9. No significant correlation between serum periostin levels and peripheral blood eosinophils was found.

CONCLUSION

Serum periostin levels were no significantly different between wheezer pre-schoolers with positive and negative API. More studies are needed to confirm this finding.

Effect of foods and Mediterranean diet during pregnancy and first years of life on wheezing, rhinitis and dermatitis in preschoolers

BACKGROUND

There is a conflictive position if some foods and Mediterranean diet (MedDiet) consumed by the mother during pregnancy and by the child during the first years of life can be protective for current wheezing, rhinitis and dermatitis at preschool age.

METHODS

Questionnaires of epidemiological factors and food intake by the mother during pregnancy and later by the child were filled in by parents in two surveys at two different time points (1.5 yrs and 4 yrs of life) in 1000 preschoolers.

RESULTS

The prevalences of current wheezing, rhinitis and dermatitis were 18.8%, 10.4%, and 17.2%, respectively. After multiple logistic analysis children who were low fruit consumers (never/occasionally) and high fast-food consumers (≥3 times/week) had a higher risk for current wheezing; while intermediate consumption of meat (1 or 2 times/week) and low of pasta by mothers in pregnancy were protected. For current rhinitis, low fruit consumer children were at higher risk; while those consuming meat <3 times/week were protected. For current dermatitis, high fast food consumption by mothers in pregnancy; and low or high consumption of fruit, and high of potatoes in children were associated to higher prevalence. Children consuming fast food >1 times/week were protected for dermatitis. MedDiet adherence by mother and child did not remain a protective factor for any outcome.

CONCLUSION

Low consumption of fruits and high of meat by the child, and high consumption of potatoes and pasta by the mother had a negative effect on wheezing, rhinitis or dermatitis; while fast food consumption was inconsistent.

Many respiratory viruses have temporal association with meningococcal disease

BACKGROUND

Previous ecological studies have shown a temporal and spatial association between influenza epidemics and meningococcal disease (MNG); however, none have examined more than two respiratory viruses.

METHODS

Data were obtained in Chile between 2000 and 2005 on confirmed cases of MNG and all confirmed cases of respiratory viruses (influenza A and B; parainfluenza; adenovirus; and respiratory syncytial virus [RSV]). Both variables were divided by epidemiological weeks, age range, and regions. Models of transference functions were run for rates of MNG.

RESULTS

In this period, 1022 reported cases of MNG and 34,737 cases of respiratory virus were identified (25,137 RSV; 4300 parainfluenza; 2527 influenza-A; 356 influenza-B; and 2417 adenovirus). RSV was the major independent virus temporally associated to MNG (it appears one week before MNG), followed by parainfluenza, influenza-B, adenovirus, and influenza-A.

CONCLUSIONS

The rate of MNG in Chile is temporally associated to all of the respiratory viruses studied, but with variability according age range, and regions.

[Validation of a Spanish version of the Childhood Asthma Control Test (Sc-ACT) for use in Spain]

OBJECTIVE

The Childhood Asthma Control Test (c-ACT) is a validated tool for determining pediatric asthma control. However, it is not validated in the Spanish language in Spain. We evaluated the psychometric properties of the Spanish version of the Childhood Asthma Control Test (Sc-ACT) for assessing asthma control in children ages 4 to11.

METHODS

This national, multicentre, prospective study was conducted in Spain with asthmatic children and their caregivers. Patients were assessed at 3 visits (Baseline, 2 Weeks, and 4 Months). Clinical variables included: symptoms, exacerbations, FEV1, asthma classification, PAQLQ and PACQLQ questionnaire scores, and asthma control as perceived by physicians, patients and caregivers. The Sc-ACT feasibility, validity, reliability, and sensitivity to change were assessed.

RESULTS

A total of 394 children were included; mean (SD) time to complete the Sc-ACT was 5.3 (4.4) minutes. Sc-ACT score was correlated with asthma control as perceived by physician (-0.52), patient (-0.53), and caregiver (-0.51) and with the PAQLQ (0.56) and PACQLQ (0.55) scores. Sc-ACT was found to be significantly related to intensity and frequency of asthma symptoms. Cronbach alpha coefficient α was 0.81 and intraclass correlation coefficient was ≥0.85 for all of the items. The global effect size of Sc-ACT was 0.55. The cutoff point scores of 21 or higher indicated a good asthma control and their MCID was 4 points.

CONCLUSION

The Spanish version of the c-ACT was found to be a reliable and valid questionnaire for evaluating asthma control in Spanish-speaking children ages 4 to 11 in Spain.

Influence of Mediterranean diet on asthma in children: a systematic review and meta-analysis

BACKGROUND

There is epidemiological evidence that Mediterranean diet exposure is associated with lower asthma prevalence in children. We aimed to summarize the available data and to know whether the Mediterranean setting modifies this association.

METHODS

The literature search, up to May 2012, was on epidemiological studies in the general population of children assessing whether adherence to Mediterranean diet (measured as a score) was associated with the prevalence of 'current wheeze'; 'current severe wheeze'; or 'asthma ever'. Odds ratios (OR) of the eight included studies compared the highest tertile of the score with the lowest. Random-effects meta-analyses for the whole group of studies and stratified by Mediterranean setting (centers <100 Km from the Mediterranean coast) were performed. Differences between strata were assessed using the Q test.

RESULTS

For 'current wheeze', there was a negative significant association with the highest tertile of Mediterranean diet score (OR 0.85, 95% CI 0.75-0.98; p = 0.02), driven by Mediterranean centers (0.79, 0.66-0.94, p = 0.009), although the difference with the non-Mediterranean centers (0.91, 0.78-1.05, p = 0.18) was not significant. The results for 'current severe wheeze' were as follows: 0.82, 0.55-1.22, p = 0.330 (all); 0.66, 0.48-0.90, p = 0.008 (Mediterranean); and 0.99, 0.79-1.25, p = 0.95 (non-Mediterranean); with the difference between regions being significant. For 'asthma ever', the associations were as follows: 0.86, 0.78-0.95, p = 0.004 (all); 0.86, 0.74-1.01, p = 0.06 (Mediterranean); 0.86, 0.75-0.98; p = 0.027 (non-Mediterranean); with the difference between regions being negligible.

CONCLUSIONS

Adherence to the Mediterranean diet tended to be associated with lower occurrence of the three respiratory outcomes. For current and current severe wheeze, the association was mainly driven by the results in Mediterranean populations.

International consensus on (ICON) pediatric asthma

Asthma is the most common chronic lower respiratory disease in childhood throughout the world. Several guidelines and/or consensus documents are available to support medical decisions on pediatric asthma. Although there is no doubt that the use of common systematic approaches for management can considerably improve outcomes, dissemination and implementation of these are still major challenges. Consequently, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), recently formed by the EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus on (ICON) Pediatric Asthma. The purpose of this document is to highlight the key messages that are common to many of the existing guidelines, while critically reviewing and commenting on any differences, thus providing a concise reference. The principles of pediatric asthma management are generally accepted. Overall, the treatment goal is disease control. To achieve this, patients and their parents should be educated to optimally manage the disease, in collaboration with healthcare professionals. Identification and avoidance of triggers is also of significant importance. Assessment and monitoring should be performed regularly to re-evaluate and fine-tune treatment. Pharmacotherapy is the cornerstone of treatment. The optimal use of medication can, in most cases, help patients control symptoms and reduce the risk for future morbidity. The management of exacerbations is a major consideration, independent of chronic treatment. There is a trend toward considering phenotype-specific treatment choices; however, this goal has not yet been achieved.

Urinary leukotriene excretion profile in children with exercise-induced asthma compared with controls: a preliminary study

BACKGROUND

Leukotrienes are among the most important mediators associated with inflammatory responses in patients with exercise induced asthma (EIA). The aim of this study was to investigate the impact of exercise on the urinary leukotriene profile. Hence, we compared post exercise changes of urinary leukotriene E4 (LTE4) concentration between children with EIA and healthy controls.

METHODS

Ten children with EIA and 15 controls were enrolled. Both groups underwent a standardised exercise challenge test (ECT). LTE4 concentration was measured in urine samples obtained pre and post ECT, using enzyme immunoassay and adjusted by urinary creatinine concentrations.

RESULTS

Median (minimum-maximum) pre ECT concentration of LTE4 was 17.82 (7.58-90.23 pg/ml) in EIA and 17.24 (4.64-64.02 pg/ml) in controls, p=0.86. LTE4 concentration post ECT were 23.37 (4.02-93.00 pg/ml) in EIA and 11.74 (0.13-25.09 pg/ml) in controls, p=0.02. Changes of LTE4 concentration post ECT were 2.54 (-31.98 to 43.31 pg/ml) in cases and -13.53 (-46.00 to 11.02 pg/ml) in controls, p=0.03. There was no significant correlation between basal predicted FEV(1) [%] and changes in LTE4 concentration in cases (i.e., r(s)=0.14) nor controls (i.e., r(s)=0.12). There was a tendency towards more pronounced changes in LTE4 concentration post ECT in children with moderate/mild persistent asthma compared to those with mild but intermittent asthma.

CONCLUSIONS

Children with EIA had significantly higher changes of urinary LTE4 concentrations post ECT compared to healthy controls. Urinary measurement of LTE4 may be an interesting and non-invasive option to assess control of EIA in children.

Efficacy and safety of subcutaneous omalizumab vs placebo as add-on therapy to corticosteroids for children and adults with asthma: a systematic review

BACKGROUND

Omalizumab is a humanized monoclonal anti-IgE for the treatment of severe allergic asthma. Because omalizumab targets an immune system molecule, there has been particular interest in the drug's safety.

METHODS

To establish the efficacy and safety of subcutaneous omalizumab as add-on therapy to corticosteroids, a systematic review of placebo-controlled studies was performed. Primary outcomes were reduction of steroid use and asthma exacerbations. Secondary outcome measures included lung function, rescue medication use, asthma symptoms, health-related quality of life, and adverse effects.

RESULTS

Eight trials (3,429 participants) fulfilled the selection criteria. At the end of the steroid-reduction phase, patients taking omalizumab were more likely to be able to withdraw from corticosteroids completely compared with those taking placebo (relative risk [RR] = 1.80; 95% CI, 1.42-2.28; P = .00001). Omalizumab patients showed a decreased risk of asthma exacerbations at the end of the stable (RR = 0.57; 95% CI, 0.48-0.66; P = .0001) and adjustable-steroid phases (RR = 0.55; 95% CI, 0.47-0.64; P = .0001); post-hoc analysis suggests this effect was independent of duration of treatment, age, severity of asthma, and risk of bias. The frequency of serious adverse effects was similar in the omalizumab (3.8%) and placebo (5.3%) groups. However, injection site reactions were more frequent in the omalizumab patients (19.9% vs 13.2%). There were no indications of increased risk of hypersensitivity reactions, cardiovascular effects, or malignant neoplasms.

CONCLUSIONS

Data indicate that the efficacy of add-on omalizumab in patients with moderate-to-severe allergic asthma is accompanied by an acceptable safety profile.

Formoterol for acute asthma in the emergency department: a systematic review with meta-analysis

BACKGROUND

Although several published studies have suggested that formoterol fumarate could be equivalent to short-acting beta2-agonists (SABAs) for the treatment of asthma exacerbations, its role in acute asthma treatment remains undefined.

OBJECTIVE

To evaluate the efficacy and safety of inhaled formoterol (compared with SABAs) for the emergency department treatment of patients with acute asthma.

METHODS

Systematic searches were conducted in MEDLINE, EMBASE, the Cochrane Controlled Trials Register, and manufactures' trial registers, without language restriction. The primary outcomes were spirometric measures. The secondary outcomes included final serum potassium level, heart rate, electrocardiographic QT interval corrected for heart rate, and total withdrawals.

RESULTS

Nine randomized controlled trials (including 576 participants) were selected. No significant difference could be detected between formoterol and SABAs for any of the selected time points: at 30 to 40 minutes after the first administration of study drugs (standardized mean difference, -0.19; 95% confidence interval, -0.56 to 0.17; I2 = 75%), at the end of treatment (standardized mean difference, -0.25; 95% confidence interval, -0.72 to 0.13; I2 = 89%), and at 60 to 90 minutes after the last dose (standardized mean difference, -0.13; 95% confidence interval, -0.55 to 0.28; I2 = 80%). Similarly, there were no significant differences between formoterol and SABAs regarding final serum potassium level, heart rate, QT interval, hospitalization rate, and total withdrawals.

CONCLUSIONS

This review suggests that high-dose formoterol administered via dry powder inhaler is well tolerated and provides rapid and effective bronchodilation, similar to high-dose salbutamol or terbutaline via metered-dose inhaler or nebulizer. Formoterol may be used in the treatment of acute asthma in the emergency department setting.

Effectiveness of asthma education with and without a self-management plan in hospitalized children

Background. Formal education in primary care can reduce asthma exacerbations. However, there are few studies in hospitalized children, with none originating in Latin America. Methods. A prospective randomized study was designed to evaluate whether a full education with self-management plan (ESM) was more effective than an education without self-management plan (E) in reducing asthma hospitalization. Children (5 to 15 years of age) who were hospitalized for an asthma attack were divided in two groups. Children in the E group received general instructions based on a booklet. Those in the ESM group received the same booklet plus a self-management guide and a puzzle game that reinforces the lessons learned in the booklet. Patients were interviewed every 3 months, by telephone, for one year. Interviewers recording the number of hospitalizations, exacerbations, and emergency visits for asthma and oral steroid burst uses. Results. From 88 children who met the inclusion criteria, 77 (86%) completed one year of follow-up (41 from E and 36 from ESM group). Overall, after one year, the hospitalization decreased by 66% and the inhaled corticosteroids therapy increased from 36% to 79%. At the end of the study, there was no difference in exacerbations, emergency visits, oral steroid burst uses, or hospitalizations between the two groups. Conclusions. Asthma education with or without a self-management plan during asthma hospitalization were effective in reducing exacerbations, emergency visits, oral steroid burst uses, and future rehospitalizations. This evidence supports the importance of providing a complete asthma education plan in any patient who is admitted for asthma exacerbation.

Safety and efficacy of combined long-acting beta-agonists and inhaled corticosteroids vs long-acting beta-agonists monotherapy for stable COPD: a systematic review

BACKGROUND

Current guidelines recommend the use of inhaled corticosteroids (ICSs) added to long-acting beta(2)-agonists (LABAs) for treatment of symptomatic patients with severe and very severe COPD. However, the evidence has been inconclusive. The aim of this review was to assess the safety and efficacy of LABAs/ICSs compared with LABA monotherapy for patients with moderate-to-very severe COPD.

METHODS

Systematic searches were conducted on MEDLINE, EMBASE, the Cochrane Controlled Trials Register, and the trial registers of manufacturers, without language restriction. Primary outcomes were COPD exacerbations and mortality. Secondary outcomes included lung function, health-related quality of life, and adverse effects.

RESULTS

Eighteen randomized controlled trials (12,446 participants) were selected. Therapy with LABAs/ICSs did not decrease the number of severe exacerbations (relative risk [RR], 0.91; 95% CI, 0.82 to 1.01; I(2) = 1%), or all-cause mortality (RR, 0.90; 95% CI, 0.76 to 1.06; I(2) = 0%), respiratory mortality (RR, 0.80; 95% CI, 0.61 to 1.05; I(2) = 0%), and cardiovascular mortality (RR, 1.22; 95% CI, 0.88 to 1.71; I(2) = 0%). To the contrary, the number of moderate exacerbations (RR, 0.84; 95% CI, 0.74 to 0.96; I(2) = 50%) and the St. George respiratory questionnaire total score (weighted mean difference, -1.88; 95% CI, -2.44 to -1.33; I(2) = 29%) were significantly reduced with LABA/ICS therapy. Although therapy with LABAs/ICSs increases FEV(1) significantly (0.06 and 0.04 L, respectively), they were associated with an increased risk of pneumonia (RR, 1.63; 95% CI, 1.35 to 1.98; I(2) = 20%).

CONCLUSIONS

Compared with LABA monotherapy, the magnitude of the benefits of LABA/ICS therapy did not reach that of the criteria for predefined clinically important effects and were associated with serious adverse effects.

Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach

There is poor agreement on definitions of different phenotypes of preschool wheezing disorders. The present Task Force proposes to use the terms episodic (viral) wheeze to describe children who wheeze intermittently and are well between episodes, and multiple-trigger wheeze for children who wheeze both during and outside discrete episodes. Investigations are only needed when in doubt about the diagnosis. Based on the limited evidence available, inhaled short-acting beta(2)-agonists by metered-dose inhaler/spacer combination are recommended for symptomatic relief. Educating parents regarding causative factors and treatment is useful. Exposure to tobacco smoke should be avoided; allergen avoidance may be considered when sensitisation has been established. Maintenance treatment with inhaled corticosteroids is recommended for multiple-trigger wheeze; benefits are often small. Montelukast is recommended for the treatment of episodic (viral) wheeze and can be started when symptoms of a viral cold develop. Given the large overlap in phenotypes, and the fact that patients can move from one phenotype to another, inhaled corticosteroids and montelukast may be considered on a trial basis in almost any preschool child with recurrent wheeze, but should be discontinued if there is no clear clinical benefit. Large well-designed randomised controlled trials with clear descriptions of patients are needed to improve the present recommendations on the treatment of these common syndromes.

Safety of regular use of long-acting beta agonists as monotherapy or added to inhaled corticosteroids in asthma. A systematic review

BACKGROUND

Safety of long-acting beta agonists (LABA) has been questioned and recent evidence suggested a detrimental effect on asthma control as well as an increased risk of death.

OBJECTIVE

To evaluate the safety of regular use of LABA compared with placebo or LABA added to inhaled corticosteroids (ICS) compared with ICS in persistent asthma.

METHODS

Randomized studies from MEDLINE, EMBASE, and Cochrane Controlled Trials Register were identified. Additionally, AstraZeneca, GlaxoSmithKline, Novartis and FDA clinical trials databases were searched. Primary outcomes were asthma exacerbations (AE) requiring systemic corticosteroids or hospitalization, life-threatening exacerbations and asthma-related deaths.

RESULTS

We identified 92 randomized clinical trials with 74,092 subjects. LABA (as monotherapy) reduced exacerbations requiring corticosteroids (Relative Risk [RR]=0.80; 95% CI, 0.73-0.88), without detrimental effects on hospitalizations or life-threatening episodes. Contrarily, LABA showed a significant increase in asthma-related deaths (Relative Risk=3.83; 95% CI, 1.21-12.14). Subgroup analysis suggests that children, patients receiving salmeterol, and a duration of treatment>12 weeks are associated with a higher risk of serious adverse effects; also there was a protective effect of concomitant use of ICS. On the other hand, combination of LABA/ICS reduced exacerbations (RR=0.73; 95% CI, 0.67-0.79), and hospitalizations (RR=0.58, 95% CI, 0.45-0.74). Combined therapy was also equivalent to ICS in terms of life-threatening episodes and asthma-related deaths. Again, children and use of salmeterol were associated with an increased risk of some severe outcomes as compared with adults and formoterol users, respectively.

CONCLUSIONS

This review reinforced the international recommendations in terms of the use of LABA remains the preferred add-on therapy to ICS for patients whose disease cannot adequately controlled with ICS, and that LABA cannot be prescribed as a monotherapy. Nevertheless, in spite of the protective effect of the ICS, children and salmeterol use still show an increased risk of non-fatal serious adverse events.

Factors associated to recurrent visits to the emergency department for asthma exacerbations in children: implications for a health education programme

INTRODUCTION

Recurrent emergency department (ED) visits for asthma exacerbations produce anxiety as well as high costs to the health system and the family.

OBJECTIVE

To identify factors associated with recurrent ED visits for asthma exacerbations in children in Bogotá, Colombia.

METHODS

Data obtained from a survey of parents of 223 patients with asthma (mean +/- SD: 4.8+/-3.5 years of age) attending an asthma clinic were analysed. Demographic data and a broad asthma knowledge and attitudes questionnaire were completed by the parents.

RESULTS

Of the 223 asthmatic patients enrolled, 60 (26.9 %) had 3 or more visits to the ED for asthma in the last 6 months ("recurrent ED visits"). After controlling by age, educational level of the father, and severity of the disease; parents of children with "recurrent ED visits" were more prone to report that they attended ED because the asthma exacerbations were severe enough to go to the primary care physician (OR, 2.45; CI 95 %, 1.13-5.30; p=0.02); that asthma medications should be administered only when the children are symptomatic (OR, 3.26; CI 95 %, 1.45-7.36; p=0.004), and conversely they were less prone to have knowledge that asthma exacerbations can be avoided if medications are administered in the asymptomatic periods (OR, 0.31; CI 95 %, 0.14-0.68; p=0.003).

CONCLUSIONS

An educational programme intended to reduce the recurrent ED visits for asthma exacerbations should consider the inclusion of an explanation about the chronic nature of the disease and the importance of long-term therapy.

Risk factors for X-ray pneumonia in the first year of life and its relation to wheezing: a longitudinal study in a socioeconomic disadvantaged population

BACKGROUND

Although thousands of infants under the age of 12 months die each year from pneumonia in Latin America, little is known regarding the true occurrence of pneumonia, wheezing and other related respiratory illnesses in this age group.

METHODS AND RESULTS

In order to describe the prevalence and risk factors for radiologically confirmed pneumonia during the first year of life, a birth-cohort (n = 188) of infants born in a low-income area in Santiago, Chile was followed up monthly.

RESULTS

The prevalence of pneumonia during the first year of life was 13.3 % and there were no fatal events. Exclusive breastfeeding during the first 4 months of life was more prevalent in the non pneumonia group; conversely, wheezing episodes during 0-3 and 3-6 months of age, and hospitalization due to lower respiratory infection during 3-6 and 9-12 months of age were more prevalent in the pneumonia group. After a logistic multivariate analysis, the only risk factor that remained related with pneumonia was wheezing during the first 3 months of life (adjusted OR: 7.7, 95 CI: 1.32-44.92, p = 0.024); while breastfeeding during the first 4 months was an independent protective factor for pneumonia (adjusted OR: 0.11, 95 CI: 0.03-0.44, p = 0.002).

CONCLUSION

The significant protective effect of exclusive breast feeding against pneumonia in this cohort and the evident role of recurrent wheezing as risk factor for pneumonia during the first year of life support the implementation or reinforcement of public policies encouraging exclusive breastfeeding and an adequate management of wheezing since the first months of life.

Heightened bronchial hyperresponsiveness in the absence of heightened atopy in children with current wheezing and low income status

BACKGROUND

Although global studies such as the International Study of Asthma and Allergies in Childhood (ISAAC) have provided valuable data on the prevalence of asthma in children in Latin America, there is little information on the relationship between asthma symptoms, pulmonary function, bronchial hyperresponsiveness (BHR) and atopy in the region.

METHODS

This study examined the relationship between self-reported wheezing in the past 12 months, pulmonary function, airway responsiveness and atopy in children from a low income population in a neighbourhood of Santiago, Chile. Two random samples (100 each) of children aged 13-14 years who participated in ISAAC phase I were selected according to whether or not they reported wheezing in the past 12 months. Spirometry, the methacholine bronchial challenge test and the prick test were performed in all individuals.

RESULTS

Children who reported current wheezing had significantly higher BHR to methacholine compared with those without wheezing (71.6% vs 52.6%; p = 0.007) and no significant difference was found in forced expiratory volume in 1 s (116.7 (12.3)% vs 120.3 (14.5%); p = 0.11). The prevalence of atopy was not significantly different between those children who reported wheezing compared with those who did not (44.2% vs 42.3%; p = 0.89). Multiple regression analysis showed that only BHR to methacholine (OR 2.72, 95% CI 1.25 to 4.13; p = 0.01) and maternal asthma (OR 3.1, 95% CI 1.2 to 8.3, p = 0.03) were significant risk factors for current wheezing.

CONCLUSIONS

Our results support previous findings suggesting that in adolescents from underprivileged populations, self-reported current wheezing is related to BHR but not to atopy.

Effects of active tobacco smoking on the prevalence of asthma-like symptoms in adolescents

The prevalence of asthma in adolescents markedly varies between different localities as found by the International Study of Asthma and Allergies in Childhood (ISAAC) and this may be due to environmental factors. Although tobacco smoke exposure is related to an increase in the prevalence of asthma, there is lack of information on that respect in children from developing countries, where active tobacco smoking usually starts early in adolescence. This study was undertaken to assess the effect of tobacco smoking on the prevalence of asthma symptoms in a random sample of 4738 adolescents aged 13.4 +/- 1.05 years who responded the ISAAC video questionnaires plus questions on tobacco smoking. The prevalence of tobacco smoking in the last 12 months was 16.2%, with significant female predominance. The persistent smokers had a significantly higher prevalence of asthma-like symptoms ever and in the last 12 months (wheezing, wheezing with exercise, nocturnal wheezing, severe wheezing, and dry nocturnal cough) than ex-smokers and nonsmokers. More than 27% of asthma symptoms in our adolescents are attributable to active tobacco consumption (population attributable risk). This study strongly suggests that potent and more effective campaigns against tobacco smoking should be implemented in developing countries, where active tobacco smoking is dramatically increasing in children.

Anticholinergics in the treatment of children and adults with acute asthma: a systematic review with meta-analysis

BACKGROUND

Current guidelines recommend the use of a combination of inhaled beta(2) agonists and anticholinergics, particularly for patients with acute severe or life threatening asthma in the emergency setting. However, this statement is based on a relatively small number of randomised controlled trials and related systematic reviews. A review was undertaken to incorporate the more recent evidence available about the effectiveness of treatment with a combination of beta(2) agonists and anticholinergics compared with beta(2) agonists alone in the treatment of acute asthma.

METHODS

A search was conducted of all randomised controlled trials published before April 2005.

RESULTS

Data from 32 randomised controlled trials (n = 3611 subjects) showed significant reductions in hospital admissions in both children (RR = 0.73; 95% CI 0.63 to 0.85, p = 0.0001) and adults (RR = 0.68; 95% CI 0.53 to 0.86, p = 0.002) treated with inhaled anticholinergic agents. Combined treatment also produced a significant increase in spirometric parameters 60-120 minutes after the last treatment in both children (SMD = -0.54; 95% CI -0.28 to -0.81, p = 0.0001) and adults (SMD = -0.36; 95% CI -0.23 to -0.49, p = 0.00001).

CONCLUSIONS

This review strongly suggests that the addition of multiple doses of inhaled ipratropium bromide to beta(2) agonists is indicated as the standard treatment in children, adolescents, and adults with moderate to severe exacerbations of asthma in the emergency setting.

beta-agonists through metered-dose inhaler with valved holding chamber versus nebulizer for acute exacerbation of wheezing or asthma in children under 5 years of age: a systematic review with meta-analysis

OBJECTIVE

To compare the efficacy of beta-agonists given by metered-dose inhaler with a valved holding chamber (MDI+VHC) or nebulizer in children under 5 years of age with acute exacerbations of wheezing or asthma in the emergency department setting.

STUDY DESIGN

Published (1966 to 2003) randomized, prospective, controlled trials were retrieved through several different databases. The primary outcome measure was hospital admission.

RESULTS

Six trials (n=491) met criteria for inclusion. Patients who received beta-agonists by MDI+VHC showed a significant decrease in the admission rate compared with those by nebulizer (OR, 0.42; 95% CI, 0.24-0.72; P=.002); this decrease was even more significant among children with moderate to severe exacerbations (OR, 0.27; 95% CI, 0.13-0.54; P=.0003). Finally, measure of severity (eg, clinical score) significantly improved in the group who received beta-agonists by MDI+VHC in comparison to those who received nebulizer treatment (standardized mean difference, -0.44; 95% CI, -0.68 to -0.20; P=.0003).

CONCLUSIONS

The use of an MDI+VHC was more effective in terms of decreasing hospitalization and improving clinical score than the use of a nebulizer in the delivery of beta-agonists to children under 5 years of age with moderate to severe acute exacerbations of wheezing or asthma.

Comparative randomized trial of azithromycin versus erythromycin and amoxicillin for treatment of community-acquired pneumonia in children

Our objective was to compare the clinical efficacy of azithromycin vs. erythromycin and amoxicillin in the treatment of presumed bacterial community-acquired pneumonia in ambulatory children, and to evaluate the etiologies of these illnesses. One hundred and ten children, aged 1 month to 14 years, were enrolled between January 1996-January 1999. Children were distributed into two groups according to clinical and radiological patterns: classic or atypical pneumonia. Patients with classic pneumonia were randomly assigned to receive oral amoxicillin 75 mg/kg/day for 7 days, or azithromycin 10 mg/kg/day for 3 days; patients with atypical pneumonia received azithromycin 10 mg/kg/day for 3 days, or erythromycin 50 mg/kg/day for 14 days. Chest X-ray, clinical, and laboratory parameters were obtained on enrollment. Clinic visits were performed on days 3, 7, and 14, and chest X-ray follow-up on days 7 and 14. Microbiological diagnosis of classic pathogens was based on blood and bronchial secretion cultures. The diagnosis of atypical pathogens C. pneumoniae, C. trachomatis, and M. pneumoniae was based on PCR and serologic tests.Forty-seven children met the criteria for classic pneumonia (23 children received azithromycin, and 24 received amoxicillin), and 59 children had atypical pneumonia (33 children were treated with azithromycin, and 26 with erythromycin). Demographic characteristics at enrollment were similar between children with classic pneumonia treated with azithromycin and erythromycin and children treated with azithromycin and erythromycin for atypical pneumonia. However, on day 7, children with classic pneumonia who received azithromycin normalized their chest X-ray more often than those who received amoxicillin (81.0% vs. 60.9%, respectively, P = 0.009). The same was true for children with atypical pneumonia; their chest X-rays had normalized by day 14 (100% in those with azithromycin vs. 81% in those with erythromycin, P = 0.059). Also, children with atypical pneumonia treated with azithromycin had earlier cessation of cough than children treated with erythromycin (3.6 +/- 1.9 vs. 5.5 +/- 3.6 days respectively, P = 0.02). There were only three children with side effects (mild diarrhea, all in the erythromycin group). Etiological agents were identified in 41% of children. In conclusion, azithromycin is an effective therapeutic option for the treatment of community-acquired classic and atypical pneumonia in children.

Recurrent pneumonia as warning manifestation for suspecting primary immunodeficiencies in children

Two hundred and eight children with recurrent pneumonia were studied over a 5-year period. Among these patients we found 10 cases with primary immunodeficiency disease: 6 cases of IgA deficiency, 1 case of X-linked agammaglobulinemia, 1 case of common variable immunodeficiency, 1 case of hyper IgM syndrome, and 1 case of Wiskott-Aldrich syndrome. This study describes the clinical features of these cases and assesses the usefulness of our immunodeficiency screening protocol. In this group 6 were males; the mean age at first episode of pneumonia was 3 years (range 3 months to 18 years), and the age of diagnosis ranged between 10 months and 19 years. The average number of episodes of pneumonia in each patient was 5 (range 2 to 12), and the number of hospitalizations ranged up to 13. The etiologic agents isolated from this recurrent pneumonia were S. pneumoniae, Moraxella, adenovirus, respiratory syncytial virus, and influenza B virus. Intravenous immunoglobulin was used in four cases. Two patients had chronic pulmonary damage with bronchiectasis and interstitial pneumonia. Only one patient died (Wiskott-Aldrich syndrome) during the follow-up from an intracranial hemorrhage. We found that the screening protocol applied to patients with recurrent pneumonia is a useful tool for ruling out the primary immunodeficiency disorders.

Dog exposure in infancy decreases the subsequent risk of frequent wheeze but not of atopy

BACKGROUND

Influence of household pets in the development of childhood asthma or atopy has been controversial.

OBJECTIVE

The purpose of this study was to investigate whether pet exposure in early life decreases the subsequent risk of frequent wheezing and/or allergic sensitization.

METHODS

This was a prospective observational birth cohort study. The setting was a large health maintenance organization in Tucson, Ariz; the subjects were a population sample of 1246 newborns enrolled at birth and followed prospectively to age 13 years. The main outcome measures were as follows: time to first report of frequent wheezing (>3 episodes in the past year), skin prick test reactivity at 6 years and 11 years of age, and total serum IgE at 9 months, 6 years, and 11 years of age.

RESULTS

Children living in households with > or =1 indoor dogs at birth were less likely to develop frequent wheeze than those not having indoor dogs (P =.004). This inverse association was confined to children without parental asthma (hazard ratio = 0.47; P <.001 [Cox regression]) and was not evident for children with parental asthma (hazard ratio = 0.96; P =.87). Adjustment by potential confounders did not change the results. Indoor cat exposure was not significantly associated with the risk of frequent wheezing. Neither cat exposure in early life nor dog exposure in early life was associated with skin prick test reactivity or total serum IgE at any age.

CONCLUSION

Dog exposure in early life might prevent the development of asthma-like symptoms, at least in low-risk children with no family history of asthma. Nevertheless, early pet exposure does not seem to significantly influence the development of allergic sensitization.

Siblings, day-care attendance, and the risk of asthma and wheezing during childhood

BACKGROUND

Young children with older siblings and those who attend day care are at increased risk for infections, which in turn may protect against the development of allergic diseases, including asthma. However, the results of studies examining the relation between exposure to other children and the subsequent development of asthma have been conflicting.

METHODS

In a study involving 1035 children followed since birth as part of the Tucson Children's Respiratory Study, we determined the incidence of asthma (defined as at least one episode of asthma diagnosed by a physician when the child was 6 to 13 years old) and the prevalence of frequent wheezing (more than three wheezing episodes during the preceding year) in relation to the number of siblings at home and in relation to attendance at day care during infancy.

RESULTS

The presence of one or more older siblings at home protected against the development of asthma (adjusted relative risk for each additional older sibling, 0.8; 95 percent confidence interval, 0.7 to 1.0; P=0.04), as did attendance at day care during the first six months of life (adjusted relative risk, 0.4; 95 percent confidence interval, 0.2 to 1.0; P=0.04). Children with more exposure to other children at home or at day care were more likely to have frequent wheezing at the age of 2 years than children with little or no exposure (adjusted relative risk, 1.4; 95 percent confidence interval, 1.1 to 1.8; P=0.01) but were less likely to have frequent wheezing from the age of 6 (adjusted relative risk, 0.8; 95 percent confidence interval, 0.6 to 1.0; P=0.03) through the age of 13 (adjusted relative risk, 0.3; 95 percent confidence interval, 0.2 to 0.5; P<0.001).

CONCLUSIONS

Exposure of young children to older children at home or to other children at day care protects against the development of asthma and frequent wheezing later in childhood.

Randomized trial of salbutamol via metered-dose inhaler with spacer versus nebulizer for acute wheezing in children less than 2 years of age

The aim of this study was to compare the efficacy of salbutamol delivered via a metered-dose inhaler with a spacer and facial mask (MDI-S) vs. a nebulizer (NEB) for the treatment of acute exacerbations of wheezing in children. In a single-blind, prospective, randomized clinical trial, 123 outpatients (1-24 months of age), presenting with "moderate to severe" wheezing, were seen in the emergency department. Children were randomly assigned to one of two salbutamol treatment groups. In the first hour, the MDI-S group received 2 puffs (100 microg/puff) every 10 min for 5 doses, and the NEB group received 0.25 mg/kg every 13 min for 3 doses. If the clinical score was >5 at the end of the first hour, the patients received another hour of the same treatment and also betamethasone (0.5 mg/kg intramuscular). On enrollment and after the first and the second hour of treatment each child had a validated clinical score assigned by a blinded investigator. There were no differences at the time of admission to the emergency department between groups in clinical score or demographic data. Success (clinical score </=5) after the first hour of treatment was 90% (56/62) in the MDI-S group and 71% (43/61) in the NEB group (odds ratio 3.9, 95% confidence interval 1.5-10.4, P = 0.01). After the second hour, the success was 100% in the MDI-S and 94% in the NEB (P > 0.05). We conclude that in this study population, children less than 2 years of age with moderate-severe exacerbations of wheezing responded faster to salbutamol delivered by MDI with a spacer and facial mask than to salbutamol delivered by nebulizer.