1
|
Li H, Dong T, Luan J. Efficacy and safety of fluticasone propionate/salmeterol and fluticasone propionate monotherapy in step-up treatment of childhood asthma: A systematic review and meta-analysis. Heart Lung 2024; 63:23-34. [PMID: 37740997 DOI: 10.1016/j.hrtlng.2023.09.004] [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: 06/29/2023] [Revised: 08/10/2023] [Accepted: 09/10/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Asthma is a chronic respiratory disease that affects millions of children worldwide and can impair their quality of life and development. Inhaled glucocorticoids are the mainstay of asthma treatment, but some children require step-up therapy with additional drugs to achieve symptom control. Fluticasone propionate and salmeterol (FSC) has been shown to reduce asthma exacerbations and improve lung function in adults. However, the evidence for its efficacy and safety in children is limited. OBJECTIVE This study aims to provide a comprehensive basis for treatment selection by summarizing existing clinical randomized controlled trials (RCTs) on the efficacy of FSC compared to fluticasone propionate (FP) monotherapy in children with asthma who require step-up treatment. METHODS Five online databases and three clinical trial registration platforms were systematically searched. The effect size and corresponding 95% confidence interval (CI) were calculated based on the heterogeneity among the included studies. RESULTS Twelve RCTs were identified and a total of 9, 859 patients were involved. The results of the meta-analysis revealed that the use of FSC was associated with a greater reduction in the incidence of asthma exacerbations than FP alone when the dose of FP was the same or when the duration of treatment exceeded 12 weeks. In addition, FSC resulted in a greater proportion of time with asthma-free and without the use of albuterol compared to FP alone when the duration of treatment exceeded 12 weeks. No significant differences were observed between FSC and FP alone in the incidence of drug-related adverse events and other adverse events. CONCLUSION Both FSC and FP alone are viable options for the initial selection of step-up treatment in asthmatic children. While, FSC treatment demonstrates a greater likelihood of reducing asthma exacerbations which is particularly important for reducing the personnel, social and economic burden in children requiring step-up asthma treatment.
Collapse
Affiliation(s)
- Hua Li
- Department of Pharmacy, Shanxi Provincial Children's Hospital, Taiyuan, Shanxi, China
| | - Tao Dong
- Department of Pharmacy, Beijing Hospital of Integrated Traditional Chinese and Western Medicine, Beijing, China
| | - Jinling Luan
- Pediatrics, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang 310000, China.
| |
Collapse
|
2
|
Custovic D, Fontanella S, Custovic A. Understanding progression from pre-school wheezing to school-age asthma: Can modern data approaches help? Pediatr Allergy Immunol 2023; 34:e14062. [PMID: 38146116 DOI: 10.1111/pai.14062] [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] [Received: 11/27/2023] [Accepted: 12/01/2023] [Indexed: 12/27/2023]
Abstract
Preschool wheezing and childhood asthma create a heavy disease burden which is only exacerbated by the complexity of the conditions. Preschool wheezing exhibits both "curricular" and "aetiological" heterogeneity: that is, heterogeneity across patients both in the time-course of its development and in its underpinning pathological mechanisms. Since these are not fully understood, but clinical presentations across patients may nonetheless be similar, current diagnostic labels are imprecise-not mapping cleanly onto underlying disease mechanisms-and prognoses uncertain. These uncertainties also make a identifying new targets for therapeutic intervention difficult. In the past few decades, carefully designed birth cohort studies have collected "big data" on a large scale, incorporating not only a wealth of longitudinal clinical data, but also detailed information from modalities as varied as imaging, multiomics, and blood biomarkers. The profusion of big data has seen the proliferation of what we term "modern data approaches" (MDAs)-grouping together machine learning, artificial intelligence, and data science-to make sense and make use of this data. In this review, we survey applications of MDAs (with an emphasis on machine learning) in childhood wheeze and asthma, highlighting the extent of their successes in providing tools for prognosis, unpicking the curricular heterogeneity of these conditions, clarifying the limitations of current diagnostic criteria, and indicating directions of research for uncovering the etiology of the diseases underlying these conditions. Specifically, we focus on the trajectories of childhood wheeze phenotypes. Further, we provide an explainer of the nature and potential use of MDAs and emphasize the scope of what we can hope to achieve with them.
Collapse
Affiliation(s)
- Darije Custovic
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Sara Fontanella
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, UK
| |
Collapse
|
3
|
Xing Y, Leung ASY, Wong GWK. From preschool wheezing to asthma: Environmental determinants. Pediatr Allergy Immunol 2023; 34:e14049. [PMID: 38010001 DOI: 10.1111/pai.14049] [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] [Received: 10/19/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023]
Abstract
Wheezing is common among preschool children, representing a group of highly heterogeneous conditions with varying natural history. Several phenotypes of wheezing have been proposed to facilitate the identification of young children who are at risk of subsequent development of asthma. Epidemiological and immunological studies across different populations have revealed the key role of environmental factors in influencing the progression from preschool wheezing to childhood asthma. Significant risk factors include severe respiratory infections, allergic sensitization, and exposure to tobacco smoke. In contrast, a farming/rural environment has been linked to asthma protection in both human and animal studies. Early and intense exposures to microorganisms and microbial metabolites have been demonstrated to alter host immune responses to allergens and viruses, thereby driving the trajectory away from wheezing illness and asthma. Ongoing clinical trials of candidate microbes and microbial products have shown promise in shaping the immune function to reduce episodes of viral-induced wheezing. Moreover, restoring immune training may be especially important for young children who had reduced microbial exposure due to pandemic restrictions. A comprehensive understanding of the role of modifiable environmental factors will pave the way for developing targeted prevention strategies for preschool wheezing and asthma.
Collapse
Affiliation(s)
- Yuhan Xing
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Special Administrative Region, China
| | - Agnes Sze-Yin Leung
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Special Administrative Region, China
| | - Gary Wing-Kin Wong
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Special Administrative Region, China
| |
Collapse
|
4
|
van Breugel M, Fehrmann RSN, Bügel M, Rezwan FI, Holloway JW, Nawijn MC, Fontanella S, Custovic A, Koppelman GH. Current state and prospects of artificial intelligence in allergy. Allergy 2023; 78:2623-2643. [PMID: 37584170 DOI: 10.1111/all.15849] [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: 04/20/2023] [Revised: 07/08/2023] [Accepted: 07/31/2023] [Indexed: 08/17/2023]
Abstract
The field of medicine is witnessing an exponential growth of interest in artificial intelligence (AI), which enables new research questions and the analysis of larger and new types of data. Nevertheless, applications that go beyond proof of concepts and deliver clinical value remain rare, especially in the field of allergy. This narrative review provides a fundamental understanding of the core concepts of AI and critically discusses its limitations and open challenges, such as data availability and bias, along with potential directions to surmount them. We provide a conceptual framework to structure AI applications within this field and discuss forefront case examples. Most of these applications of AI and machine learning in allergy concern supervised learning and unsupervised clustering, with a strong emphasis on diagnosis and subtyping. A perspective is shared on guidelines for good AI practice to guide readers in applying it effectively and safely, along with prospects of field advancement and initiatives to increase clinical impact. We anticipate that AI can further deepen our knowledge of disease mechanisms and contribute to precision medicine in allergy.
Collapse
Affiliation(s)
- Merlijn van Breugel
- Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- MIcompany, Amsterdam, the Netherlands
| | - Rudolf S N Fehrmann
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Faisal I Rezwan
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
- Department of Computer Science, Aberystwyth University, Aberystwyth, UK
| | - John W Holloway
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
- National Institute for Health and Care Research Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Martijn C Nawijn
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Sara Fontanella
- National Heart and Lung Institute, Imperial College London, London, UK
- National Institute for Health and Care Research Imperial Biomedical Research Centre (BRC), London, UK
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, UK
- National Institute for Health and Care Research Imperial Biomedical Research Centre (BRC), London, UK
| | - Gerard H Koppelman
- Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| |
Collapse
|
5
|
Lau HX, Chen Z, Van Bever H, Tham EH, Chan YH, Yap QV, Goh AEN, Teoh OH, Tan KH, Yap FKP, Godfrey KM, Eriksson JG, Chong YS, Lee BW, Shek LPC, Loo EXL. Clinical predictors of wheeze trajectories and associations with allergy in Asian children. Ann Allergy Asthma Immunol 2023; 131:466-473.e6. [PMID: 37419414 PMCID: PMC10561605 DOI: 10.1016/j.anai.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/04/2023] [Accepted: 06/27/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Childhood wheezing is a highly heterogeneous condition with an incomplete understanding of the characteristics of wheeze trajectories, particularly for persistent wheeze. OBJECTIVE To characterize predictors and allergic comorbidities of distinct wheeze trajectories in a multiethnic Asian cohort. METHODS A total of 974 mother-child pairs from the prospective Growing Up in Singapore Towards healthy Outcomes (GUSTO) cohort were included in this study. Wheeze and allergic comorbidities in the first 8 years of life were assessed using the modified International Study of Asthma and Allergies in Childhood questionnaires and skin prick tests. Group-based trajectory modeling was used to derive wheeze trajectories and regression was used to assess associations with predictive risk factors and allergic comorbidities. RESULTS There were 4 wheeze trajectories derived, including the following: (1) early-onset with rapid remission from age 3 years (4.5%); (2) late-onset peaking at age 3 years and rapidly remitting from 4 years (8.1%); (3) persistent with a steady increase to age 5 years and high wheeze occurrence until 8 years (4.0%); and (4) no or low wheeze (83.4%). Early-onset wheezing was associated with respiratory infections during infancy and linked to subsequent nonallergic rhinitis throughout childhood. Late-onset and persistent wheeze shared similar origins characterized by parent-reported viral infections in later childhood. However, persistent wheezing was generally more strongly associated with a family history of allergy, parent-reported viral infections in later childhood, and allergic comorbidities as compared with late-onset wheezing. CONCLUSION The timing of viral infection occurrence may determine the type of wheeze trajectory development in children. Children with a family history of allergy and viral infections in early life may be predisposed to persistent wheeze development and the associated comorbidities of early allergic sensitization and eczema.
Collapse
Affiliation(s)
- Hui Xing Lau
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Zhaojin Chen
- Department of Biostatistics, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Hugo Van Bever
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Elizabeth Huiwen Tham
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore; Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore, Singapore; Human Potential Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Yiong Huak Chan
- Department of Biostatistics, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Qai Ven Yap
- Department of Biostatistics, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Anne Eng Neo Goh
- Department of Paediatrics, KK Women's and Children's Hospital (KKH), Singapore, Singapore
| | - Oon Hoe Teoh
- Department of Paediatrics, KK Women's and Children's Hospital (KKH), Singapore, Singapore
| | - Kok Hian Tan
- Department of Maternal Fetal Medicine, KKH, Singapore, Singapore
| | - Fabian Kok Peng Yap
- Department of Paediatrics, KK Women's and Children's Hospital (KKH), Singapore, Singapore; Duke- National University of Singapore (NUS) Medical School, Singapore, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Keith M Godfrey
- Faculty of Medicine, School of Human Development and Health, University of Southampton, Southampton, United Kingdom; National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton National Health Service (NHS) Foundation Trust and University of Southampton, Southampton, United Kingdom; Medical Research Council (MRC) Lifecourse Epidemiology Unit, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Johan G Eriksson
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore; Human Potential Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore; Folkhälsan Research Center, Helsinki, Finland; Department of General Practice and Primary Health Care, University of Helsinki, Finland; Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore (NUS) and National University Health System, Singapore
| | - Yap Seng Chong
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore; Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore (NUS) and National University Health System, Singapore
| | - Bee Wah Lee
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Lynette Pei-Chi Shek
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Evelyn Xiu Ling Loo
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore; Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore; Human Potential Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore.
| |
Collapse
|
6
|
Håkansson KEJ, Guerrero SC, Backer V, Ulrik CS, Rastogi D. Burden and unmet need for specialist care in poorly controlled and severe childhood asthma in a Danish nationwide cohort. Respir Res 2023; 24:173. [PMID: 37370052 PMCID: PMC10304602 DOI: 10.1186/s12931-023-02482-7] [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: 12/15/2022] [Accepted: 06/21/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Asthma is a common disease in childhood and adolescence with lifelong consequences particularly among those at risk of severe disease, poor control and/or frequent exacerbations. Specialist care is recommended for at-risk children and adolescents, yet access to specialist management in free-to-access healthcare settings remains poorly understood. METHODS A Danish nationwide cohort of children and adolescents aged 2-17 years with persistent asthma, defined as repeated redemption of inhaled corticosteroids (ICS) during 2015, were followed for two years, to identify at-risk children and adolescents comprising those with severe asthma (classified according to GINA 2020 guidelines), poor control (defined as use of 400/600 (ages 2-11/12 +) annual doses of short-acting bronchodilators), or frequent exacerbations (defined as use of oral steroids or hospitalization), and access to specialist care. The population is chosen due to detailed medical records in the setting of universal health care. RESULTS The cohort comprised of 29,851 children and adolescents (59% boys), with a median age of 9 years. While 17% of children were on high dose ICS, 22% were on daily ICS below GINA low dose cut-off. Prevalence of severe asthma (3.0-6.5%) was lower than poor asthma control (6.4-25%); both declined from childhood to adolescence. Exacerbations occurred in 7.1-9.0% of children, with median number of exacerbations being 1 (IQR 1-1). Despite being classified as having mild-to-moderate asthma, 15% had poor asthma control and 3.8% experienced exacerbation(s), respectively. While 61% of children with severe asthma and 58% with exacerbation-prone disease were in specialist care, only 24% with uncontrolled disease were receiving specialist care. Of children and adolescents using high-dose ICS, 71% were managed in primary care, while the use of additional controllers was more common in specialist care. CONCLUSIONS Throughout childhood and adolescence, there was a high prevalence of severe asthma and poor control, although their prevalence declined with age. We demonstrate a large unmet need for specialist care among children with at-risk asthma, particularly among those with poorly controlled asthma, even in a system with free-to-access, tax-funded healthcare.
Collapse
Affiliation(s)
- Kjell Erik Julius Håkansson
- Department of Respiratory Medicine, Copenhagen University Hospital-Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
| | - Silvia Cabrera Guerrero
- Division of Pulmonary and Sleep Medicine, Children's National Health System, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Vibeke Backer
- Department of Otorhinolaryngology, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Copenhagen University Hospital-Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Deepa Rastogi
- Division of Pulmonary and Sleep Medicine, Children's National Health System, 111 Michigan Ave NW, Washington, DC, 20010, USA.
- Pediatrics, Genomics and Precision Medicine, George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA.
| |
Collapse
|
7
|
Khan S, Ouaalaya EH, Chauveau AD, Scherer E, Reboux G, Millon L, Deschildre A, Marguet C, Dufourg MN, Charles MA, Raherison Semjen C. Whispers of change in preschool asthma phenotypes: Findings in the French ELFE cohort. Respir Med 2023; 215:107263. [PMID: 37224890 DOI: 10.1016/j.rmed.2023.107263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 04/24/2023] [Accepted: 04/29/2023] [Indexed: 05/26/2023]
Abstract
RATIONALE Early life asthma phenotyping remains an unmet need in pediatric asthma. In France, severe pediatric asthma phenotyping has been done extensively; however, phenotypes in the general population remain underexplored. Based on the course and severity of respiratory/allergic symptoms, we aimed to identify and characterize early life wheeze profiles and asthma phenotypes in the general population. METHODS ELFE is a general population based birth cohort; which recruited 18,329 newborns in 2011, from 320 maternity units nationwide. Data was collected using parental responses to modified versions of ISAAC questionnaire on eczema, rhinitis, food allergy, cough, wheezing, dyspnoea and sleep disturbance due to wheezing at 3 time points: post-natal (2 months), infancy (age 1) and pre-school (age 5). We built a supervised trajectory for wheeze profiles and an unsupervised approach was used for asthma phenotypes. Chi squared (χ2) test or fisher's exact test was used as appropriate (p < 0.05). RESULTS Wheeze profiles and asthma phenotypes were ascertained at age 5. Supervised wheeze trajectory of 9161 children resulted in 4 wheeze profiles: Persistent (0.8%), Transient (12.1%), Incident wheezers at age 5 (13.3%) and Non wheezers (73.9%). While 9517 children in unsupervised clusters displayed 4 distinct asthma phenotypes: Mildly symptomatic (70%), Post-natal bronchiolitis with persistent rhinitis (10.2%), Severe early asthma (16.9%) and Early persistent atopy with late onset severe wheeze (2.9%). CONCLUSION We successfully determined early life wheeze profiles and asthma phenotypes in the general population of France.
Collapse
Affiliation(s)
- Sadia Khan
- Bordeaux University, INSERM, Bordeaux Population Health Research Center, Team: EPICENE, UMR1219, Bordeaux, France.
| | - El Hassane Ouaalaya
- High Institute of Nursing Professions and Health Techniques, ISPITS, Agadir, Morocco
| | | | | | | | - Laurence Millon
- Parasitology-Mycology Department, University Hospital of Besançon, Chrono-Environnement UMR 6249 CNRS, University of Bourgogne Franche-Comté, 25000, Besançon, France
| | | | | | | | | | - Chantal Raherison Semjen
- Bordeaux University, INSERM, Bordeaux Population Health Research Center, Team: EPICENE, UMR1219, Bordeaux, France
| |
Collapse
|
8
|
Fayon M, Beaufils F, Esteves P, Campagnac M, Maurat E, Michelet M, Siao-Him-Fa V, Lavrand F, Simon G, Begueret H, Berger P. Bronchial Remodeling-based Latent Class Analysis Predicts Exacerbations in Severe Preschool Wheezers. Am J Respir Crit Care Med 2023; 207:416-426. [PMID: 36108144 DOI: 10.1164/rccm.202205-0913oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Children with preschool wheezing represent a very heterogeneous population with wide variability regarding their clinical, inflammatory, obstructive, and/or remodeling patterns. We hypothesized that assessing bronchial remodeling would help clinicians to better characterize severe preschool wheezers. Objectives: The main objective was to identify bronchial remodeling-based latent classes of severe preschool wheezers. Secondary objectives were to compare cross-sectional and longitudinal clinical and biological data between classes and to assess the safety of bronchoscopy. Methods: This double-center prospective study (NCT02806466) included severe preschool wheezers (1-5 yr old) requiring fiberoptic bronchoscopy. Bronchial remodeling parameters (i.e., epithelial integrity, reticular basement membrane [RBM] thickness, mucus gland, fibrosis and bronchial smooth muscle [BSM] areas, the density of blood vessels, and RBM-BSM distance) were assessed and evaluated by latent class analysis. An independent cohort of severe preschool wheezers (NCT04558671) was used to validate our results. Measurements and Main Results: Fiberoptic bronchoscopy procedures were well tolerated. A two-class model was identified: Class BR1 was characterized by increased RBM thickness, normalized BSM area, the density of blood vessels, decreased mucus gland area, fibrosis, and RBM-BSM distance compared with Class BR2. No significant differences were found between classes in the year before fiberoptic bronchoscopy. By contrast, Class BR1 was associated with a shorter time to first exacerbation and an increased risk of both frequent (3 or more) and severe exacerbations during the year after bronchoscopy in the two cohorts. Conclusions: Assessing bronchial remodeling identified severe preschool wheezers at risk of frequent and severe subsequent exacerbations with a favorable benefit to risk ratio.
Collapse
Affiliation(s)
- Michael Fayon
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Fabien Beaufils
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Pauline Esteves
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Maryline Campagnac
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Elise Maurat
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Marine Michelet
- CHU Toulouse, Hôpital des Enfants, Service de pneumologie-allergologie pédiatrique, Service d'Anatomopathologie; and.,University Toulouse Paul Sabatier, INSERM U1043 (CPTP), F-31059 Toulouse, France
| | - Valerie Siao-Him-Fa
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Frederic Lavrand
- CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
| | - Guillaume Simon
- CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
| | - Hugues Begueret
- CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
| | - Patrick Berger
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | | |
Collapse
|
9
|
Haider S, Granell R, Curtin J, Fontanella S, Cucco A, Turner S, Simpson A, Roberts G, Murray CS, Holloway JW, Devereux G, Cullinan P, Arshad SH, Custovic A. Modeling Wheezing Spells Identifies Phenotypes with Different Outcomes and Genetic Associates. Am J Respir Crit Care Med 2022; 205:883-893. [PMID: 35050846 PMCID: PMC9838626 DOI: 10.1164/rccm.202108-1821oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Rationale: Longitudinal modeling of current wheezing identified similar phenotypes, but their characteristics often differ between studies. Objectives: We propose that a more comprehensive description of wheeze may better describe trajectories than binary information on the presence/absence of wheezing. Methods: We derived six multidimensional variables of wheezing spells from birth to adolescence (including duration, temporal sequencing, and the extent of persistence/recurrence). We applied partition-around-medoids clustering on these variables to derive phenotypes in five birth cohorts. We investigated within- and between-phenotype differences compared with binary latent class analysis models and ascertained associations of these phenotypes with asthma and lung function and with polymorphisms in asthma loci 17q12-21 and CDHR3 (cadherin-related family member 3). Measurements and Main Results: Analysis among 7,719 participants with complete data identified five spell-based wheeze phenotypes with a high degree of certainty: never (54.1%), early-transient (ETW) (23.7%), late-onset (LOW) (6.9%), persistent (PEW) (8.3%), and a novel phenotype, intermittent wheeze (INT) (6.9%). FEV1/FVC was lower in PEW and INT compared with ETW and LOW and declined from age 8 years to adulthood in INT. 17q12-21 and CDHR3 polymorphisms were associated with higher odds of PEW and INT, but not ETW or LOW. Latent class analysis- and spell-based phenotypes appeared similar, but within-phenotype individual trajectories and phenotype allocation differed substantially. The spell-based approach was much more robust in dealing with missing data, and the derived clusters were more stable and internally homogeneous. Conclusions: Modeling of spell variables identified a novel intermittent wheeze phenotype associated with lung function decline to early adulthood. Using multidimensional spell variables may better capture wheeze development and provide a more robust input for phenotype derivation.
Collapse
Affiliation(s)
- Sadia Haider
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Raquel Granell
- Medical Research Council Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - John Curtin
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Sara Fontanella
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Alex Cucco
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Stephen Turner
- Royal Aberdeen Children’s Hospital National Health Service Grampian, Aberdeen, United Kingdom;,Child Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Angela Simpson
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Graham Roberts
- Human Development and Health and,National Institute for Health Research Southampton Biomedical Research Centre, University Hospitals Southampton National Health Service Foundation Trust, Southampton, United Kingdom;,David Hide Asthma and Allergy Research Centre, Isle of Wight, United Kingdom; and
| | - Clare S. Murray
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - John W. Holloway
- Human Development and Health and,National Institute for Health Research Southampton Biomedical Research Centre, University Hospitals Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - Graham Devereux
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Paul Cullinan
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Syed Hasan Arshad
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom;,National Institute for Health Research Southampton Biomedical Research Centre, University Hospitals Southampton National Health Service Foundation Trust, Southampton, United Kingdom;,David Hide Asthma and Allergy Research Centre, Isle of Wight, United Kingdom; and
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| |
Collapse
|
10
|
Wheezing trajectories from childhood to adulthood in a population-based cohort. Allergol Int 2022; 71:200-206. [PMID: 34600810 DOI: 10.1016/j.alit.2021.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Wheezing may lead to asthma and reduced pulmonary function in later life. The study aims to identify wheezing trajectories and investigate their relation with pulmonary function and asthma-related outcomes at 22 years of age. METHODS Individuals from a population-based cohort in Brazil (1993 Pelotas Birth Cohort) with post-bronchodilator pulmonary function data at 22 years (3350) were included in the study. From parentally reported (4 and 11 years) and self-reported (15, 18 and 22 years) history of wheezing in the last 12 months, we used a group-based trajectory modelling approach to derive wheezing trajectories. RESULTS Four trajectories were identified: never/infrequent, transient-early, late-onset and persistent wheeze. After adjustments, wheezing trajectories remained associated with lower post-bronchodilator values of pulmonary function. Individuals in the persistent wheeze trajectory had a markedly poorer pulmonary function and also showed greater odds of asthma-related outcomes compared to other trajectories groups. Those following this trajectory had on average -109 ml (95% CI: -188; -35), -1.80 percentage points (95% CI: -2.73; -0.87) and -316 ml/s (95% CI: -482; -150) lower FEV1, FEV1/FVC ratio and FEF25-75% respectively; higher odds of self-reported medical diagnosis of allergy (OR 6.18; 95% CI: 3.59; 10.61) and asthma (OR 12.88; 95% CI: 8.91; 18.61) and asthma medication use (OR 9.42; 95% CI: 5.27; 16.87) compared to the never/infrequent group. CONCLUSIONS Wheezing trajectories, especially the persistent wheeze trajectory, were related to lower pulmonary function values and increased risk of asthma and allergy diagnosis in early adulthood.
Collapse
|
11
|
Asthma and Allergy: Unravelling a Tangled Relationship with a Focus on New Biomarkers and Treatment. Int J Mol Sci 2022; 23:ijms23073881. [PMID: 35409241 PMCID: PMC8999577 DOI: 10.3390/ijms23073881] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/21/2022] [Accepted: 03/21/2022] [Indexed: 12/19/2022] Open
Abstract
Asthma is a major driver of health care costs across ages. Despite widely disseminated asthma-treatment guidelines and a growing variety of effective therapeutic options, most patients still experience symptoms and/or refractoriness to standard of care treatments. As a result, most patients undergo a further intensification of therapy to optimize symptom control with a subsequent increased risk of side effects. Raising awareness about the relevance of evaluating aeroallergen sensitizations in asthmatic patients is a key step in better informing clinical practice while new molecular tools, such as the component resolved diagnosis, may be of help in refining the relationship between sensitization and therapeutic recommendations. In addition, patient care should benefit from reliable, easy-to-measure and clinically accessible biomarkers that are able to predict outcome and disease monitoring. To attain a personalized asthma management and to guide adequate treatment decisions, it is of paramount importance to expand clinicians' knowledge about the tangled relationship between asthma and allergy from a molecular perspective. Our review explores the relevance of allergen testing along the asthma patient's journey, with a special focus on recurrent wheezing children. Here, we also discuss the unresolved issues regarding currently available biomarkers and summarize the evidence supporting the eosinophil-derived neurotoxin as promising biomarker.
Collapse
|
12
|
Dai R, Miliku K, Gaddipati S, Choi J, Ambalavanan A, Tran MM, Reyna M, Sbihi H, Lou W, Parvulescu P, Lefebvre DL, Becker AB, Azad MB, Mandhane PJ, Turvey SE, Duan Q, Moraes TJ, Sears MR, Subbarao P. Wheeze trajectories: Determinants and outcomes in the CHILD Cohort Study. J Allergy Clin Immunol 2021; 149:2153-2165. [PMID: 34974064 DOI: 10.1016/j.jaci.2021.10.039] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/22/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Wheezing in early life is associated with asthma in adulthood; however, the determinants of wheezing trajectories and their associations with asthma and lung function in childhood remain poorly understood. OBJECTIVE In the CHILD Cohort Study, we aimed to identify wheezing trajectories and examine the associations between these trajectories, risk factors, and clinical outcomes at age 5 years. METHODS Wheeze data were collected at 8 time points from 3 months to 5 years of age. We used group-based trajectory models to derive wheeze trajectories among 3154 children. Associations with risk factors and clinical outcomes were analyzed by weighted regression models. RESULTS We identified 4 trajectories: a never/infrequent trajectory, transient wheeze, intermediate-onset (preschool) wheeze, and persistent wheeze. Higher body mass index was a common risk factor for all wheeze trajectories compared with that in the never/infrequent group. The unique predictors for specific wheeze trajectories included male sex, lower respiratory tract infections, and day care attendance for transient wheeze; paternal history of asthma, atopic sensitization, and child genetic risk score of asthma for intermediate wheeze; and maternal asthma for persistent wheeze. Blood eosinophil counts were higher in children with the intermediate wheeze trajectory than in those children with the other trajectories at the ages of 1 and 5 years. All wheeze trajectories were associated with decreased lung function and increased risk of asthma at age 5 years. CONCLUSIONS We identified 4 distinct trajectories in children from 3 months to 5 years of age, reflecting different phenotypes of early childhood wheeze. These trajectories were characterized by different biologic and physiologic traits and risk factors.
Collapse
Affiliation(s)
- Ruixue Dai
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Kozeta Miliku
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | | | - Jihoon Choi
- Department of Biomedical and Molecular Sciences, School of Computing, Queen's University, Kingston, Canada
| | - Amirthagowri Ambalavanan
- Department of Biomedical and Molecular Sciences, School of Computing, Queen's University, Kingston, Canada
| | - Maxwell M Tran
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Myrtha Reyna
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Hind Sbihi
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Wendy Lou
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Paula Parvulescu
- Public Health Department, Liverpool City Council, Liverpool, United Kingdom
| | | | - Allan B Becker
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | - Meghan B Azad
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | - Piush J Mandhane
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Stuart E Turvey
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Qingling Duan
- Department of Biomedical and Molecular Sciences, School of Computing, Queen's University, Kingston, Canada
| | - Theo J Moraes
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Malcolm R Sears
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Padmaja Subbarao
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada; Department of Medicine, McMaster University, Hamilton, Canada.
| |
Collapse
|
13
|
Custovic A, Siddiqui S, Saglani S. Considering biomarkers in asthma disease severity. J Allergy Clin Immunol 2021; 149:480-487. [PMID: 34942235 DOI: 10.1016/j.jaci.2021.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/25/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Abstract
Amongst patients with asthma, reliance on the type/dose of prescribed medication and symptom control does not adequately capture those at risk of adverse outcomes, and we need biomarkers for risk and treatment stratification which are consistently accurate, readily quantifiable and reproducible. The majority of patients with severe asthma, regardless of age, have predominant type-2 (T2) inflammation mediated disease, making airway/blood eosinophils, FeNO, periostin and/or allergic sensitization potentially important biomarkers for severe disease. In both adult and pediatric asthma, there is scope to improve prediction of severe attacks by using a composite T2 biomarkers of blood eosinophils and FeNO. Technological advances in component-resolved diagnostics (CRD) microarray technologies coupled with the development of interpretation software offer a possibility to use CRD as biomarkers of asthma severity amongst sensitized asthmatics. Genetic predisposition and polygenic risk scores of relevant traits (e.g., lung function, host immune responses, biomarkers of exposure from the indoor and outdoor environment, infection and microbial dysbiosis) may also contribute to prediction algorithms. We challenge the idea that asthma can be accurately defined in an individual patient by a discrete and static "endotype" (e.g., T2-high asthma). As we traverse the new era of molecular endotyping in asthma, we need to understand how relevant mechanisms impact patient outcomes, and in parallel develop new tools and approaches to stratify therapies and define individual patient trajectories.
Collapse
Affiliation(s)
- Adnan Custovic
- National Heart and Lung Institute, Imperial College London, UK.
| | - Salman Siddiqui
- Department of Respiratory Sciences, University of Leicester and NIHR Respiratory Biomedical Research Unit, Glenfield Hospital, Leicester UK
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College London, UK
| |
Collapse
|
14
|
Koefoed HJL, Zwitserloot AM, Vonk JM, Koppelman GH. Asthma, bronchial hyperresponsiveness, allergy and lung function development until early adulthood: A systematic literature review. Pediatr Allergy Immunol 2021; 32:1238-1254. [PMID: 33835532 PMCID: PMC8453965 DOI: 10.1111/pai.13516] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND It is unclear in which periods of life lung function deficits develop, and whether these are affected by risk factors such as asthma, bronchial hyper-responsiveness (BHR) and allergic comorbidity. The goal of this systematic review was to identify temporal associations of asthma, BHR and allergic comorbidity with large and small lung function development from birth until peak function in early adulthood. METHODS We searched MEDLINE, EMBASE, Web of Science and CINAHL for papers published before 01.01.2020 on risk factors and lung function measurements of large and small airways. Studies were required to report lung function at any time point or interval from birth until peak lung function (age 21-26) and include at least one candidate risk factor. RESULTS Of the 45 papers identified, 44 investigated cohorts and one was a clinical trial with follow-up. Asthma, wheezing, BHR and allergic sensitization early in life and to multiple allergens were associated with a lower lung function growth of large and small airways during early childhood compared with the control populations. Lung function development after childhood in subjects with asthma or persistent wheeze, although continuing to grow at a lower level, largely tracked parallel to non-affected individuals until peak function was attained. CLINICAL IMPLICATIONS AND FUTURE RESEARCH Deficits in lung function growth develop in early childhood, and children with asthma, BHR and early-life IgE (poly)sensitization are at risk. This period is possibly a critical window of opportunity to identify at-risk subjects and provide treatment aimed at preventing long-term sequelae of lung function.
Collapse
Affiliation(s)
- Hans Jacob L. Koefoed
- Department of Pediatric Pulmonology and Pediatric AllergologyBeatrix Children’s HospitalUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC)University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Annelies M. Zwitserloot
- Department of Pediatric Pulmonology and Pediatric AllergologyBeatrix Children’s HospitalUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC)University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Judith M. Vonk
- Groningen Research Institute for Asthma and COPD (GRIAC)University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
- Department of EpidemiologyUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Gerard H. Koppelman
- Department of Pediatric Pulmonology and Pediatric AllergologyBeatrix Children’s HospitalUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC)University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| |
Collapse
|
15
|
Robinson PFM, Fontanella S, Ananth S, Martin Alonso A, Cook J, Kaya-de Vries D, Polo Silveira L, Gregory L, Lloyd C, Fleming L, Bush A, Custovic A, Saglani S. Recurrent Severe Preschool Wheeze: From Pre-Specified Diagnostic Labels to Underlying Endotypes. Am J Respir Crit Care Med 2021; 204:523-535. [PMID: 33961755 PMCID: PMC8491264 DOI: 10.1164/rccm.202009-3696oc] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Rationale: Preschool wheezing is heterogeneous, but the underlying mechanisms are poorly understood. Objectives: To investigate lower airway inflammation and infection in preschool children with different clinical diagnoses undergoing elective bronchoscopy and BAL. Methods: We recruited 136 children aged 1–5 years (105 with recurrent severe wheeze [RSW]; 31 with nonwheezing respiratory disease [NWRD]). Children with RSW were assigned as having episodic viral wheeze (EVW) or multiple-trigger wheeze (MTW). We compared lower airway inflammation and infection in different clinical diagnoses and undertook data-driven analyses to determine clusters of pathophysiological features, and we investigated their relationships with prespecified diagnostic labels. Measurements and Main Results: Blood eosinophil counts and percentages and allergic sensitization were significantly higher in children with RSW than in children with a NWRD. Blood neutrophil counts and percentages, BAL eosinophil and neutrophil percentages, and positive bacterial culture and virus detection rates were similar between groups. However, pathogen distribution differed significantly, with higher detection of rhinovirus in children with RSW and higher detection of Moraxella in sensitized children with RSW. Children with EVW and children with MTW did not differ in terms of blood or BAL-sample inflammation, or bacteria or virus detection. The Partition around Medoids algorithm revealed four clusters of pathophysiological features: 1) atopic (17.9%), 2) nonatopic with a low infection rate and high use of inhaled corticosteroids (31.3%), 3) nonatopic with a high infection rate (23.1%), and 4) nonatopic with a low infection rate and no use of inhaled corticosteroids (27.6%). Cluster allocation differed significantly between the RSW and NWRD groups (RSW was evenly distributed across clusters, and 60% of the NWRD group was assigned to cluster 4; P < 0.001). There was no difference in cluster membership between the EVW and MTW groups. Cluster 1 was dominated by Moraxella detection (P = 0.04), and cluster 3 was dominated by Haemophilus or Staphylococcus or Streptococcus detection (P = 0.02). Conclusions: We identified four clusters of severe preschool wheeze, which were distinguished by using sensitization, peripheral eosinophilia, lower airway neutrophilia, and bacteriology.
Collapse
Affiliation(s)
- Polly F M Robinson
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain and Northern Ireland
| | - Sara Fontanella
- Imperial College London, Department of Paediatrics, London, United Kingdom of Great Britain and Northern Ireland
| | - Sachin Ananth
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain and Northern Ireland
| | - Aldara Martin Alonso
- Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - James Cook
- Royal Brompton and Harefield NHS Foundation Trust, 4964, Paediatric Respiratory Medicine, London, United Kingdom of Great Britain and Northern Ireland
| | - Daphne Kaya-de Vries
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain and Northern Ireland.,Royal Brompton and Harefield NHS Foundation Trust, 4964, Paediatric Respiratory Medicine, London, United Kingdom of Great Britain and Northern Ireland
| | - Luisa Polo Silveira
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain and Northern Ireland
| | - Lisa Gregory
- Imperial College, Leukocyte Biology, South Kensington, United Kingdom of Great Britain and Northern Ireland
| | - Clare Lloyd
- Imperial College, Leukocyte Biology, London, United Kingdom of Great Britain and Northern Ireland
| | - Louise Fleming
- Royal BRompton Hospital, Respiratory Paediatrics, London, United Kingdom of Great Britain and Northern Ireland
| | - Andrew Bush
- Imperial College and Royal Brompton Hospital, London, London, United Kingdom of Great Britain and Northern Ireland
| | - Adnan Custovic
- Imperial College London, 4615, National Heart and Lung Institute, London, United Kingdom of Great Britain and Northern Ireland
| | - Sejal Saglani
- Royal Brompton Hospital, Respiratory Paediatrics, London, United Kingdom of Great Britain and Northern Ireland;
| |
Collapse
|
16
|
Altman MC, Calatroni A, Ramratnam S, Jackson DJ, Presnell S, Rosasco MG, Gergen PJ, Bacharier LB, O'Connor GT, Sandel MT, Kattan M, Wood RA, Visness CM, Gern JE. Endotype of allergic asthma with airway obstruction in urban children. J Allergy Clin Immunol 2021; 148:1198-1209. [PMID: 33713771 PMCID: PMC8429519 DOI: 10.1016/j.jaci.2021.02.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 01/25/2021] [Accepted: 02/01/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Black and Hispanic children growing up in disadvantaged urban neighborhoods have the highest rates of asthma and related morbidity in the United States. OBJECTIVES This study sought to identify specific respiratory phenotypes of health and disease in this population, associations with early life exposures, and molecular patterns of gene expression in nasal epithelial cells that underlie clinical disease. METHODS The study population consisted of 442 high-risk urban children who had repeated assessments of wheezing, allergen-specific IgE, and lung function through 10 years of age. Phenotypes were identified by developing temporal trajectories for these data, and then compared to early life exposures and patterns of nasal epithelial gene expression at 11 years of age. RESULTS Of the 6 identified respiratory phenotypes, a high wheeze, high atopy, low lung function group had the greatest respiratory morbidity. In early life, this group had low exposure to common allergens and high exposure to ergosterol in house dust. While all high-atopy groups were associated with increased expression of a type-2 inflammation gene module in nasal epithelial samples, an epithelium IL-13 response module tracked closely with impaired lung function, and a MUC5AC hypersecretion module was uniquely upregulated in the high wheeze, high atopy, low lung function group. In contrast, a medium wheeze, low atopy group showed altered expression of modules of epithelial integrity, epithelial injury, and antioxidant pathways. CONCLUSIONS In the first decade of life, high-risk urban children develop distinct phenotypes of respiratory health versus disease that link early life environmental exposures to childhood allergic sensitization and asthma. Moreover, unique patterns of airway gene expression demonstrate how specific molecular pathways underlie distinct respiratory phenotypes, including allergic and nonallergic asthma.
Collapse
Affiliation(s)
- Matthew C Altman
- Immunology Division, Benaroya Research Institute Systems, Seattle, Wash; Department of Medicine, University of Washington, Seattle, Wash.
| | | | - Sima Ramratnam
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Daniel J Jackson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Scott Presnell
- Immunology Division, Benaroya Research Institute Systems, Seattle, Wash
| | - Mario G Rosasco
- Immunology Division, Benaroya Research Institute Systems, Seattle, Wash
| | - Peter J Gergen
- National Institute of Allergy and Infectious Diseases, Rockville, Md
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
| | - George T O'Connor
- Department of Medicine, Boston University School of Medicine, Boston, Mass
| | - Megan T Sandel
- Department of Medicine, Boston University School of Medicine, Boston, Mass
| | - Meyer Kattan
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Robert A Wood
- Department of Pediatrics, Johns Hopkins University Medical Center, Baltimore, Md
| | | | - James E Gern
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | | |
Collapse
|
17
|
Owora AH, Zhang Y. Childhood wheeze trajectory-specific risk factors: A systematic review and meta-analysis. Pediatr Allergy Immunol 2021; 32:34-50. [PMID: 32668501 DOI: 10.1111/pai.13313] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 06/08/2020] [Accepted: 06/11/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND There is growing interest in the use of latent trajectory methodology to identify wheeze patterns in heterogeneous populations of children. This study systematically reviewed and meta-analyzed childhood wheeze trajectory studies to identify childhood wheeze trajectory group-specific risk factors among children from birth through to adolescence. METHODS We included studies that used latent trajectory methodology to identify wheeze trajectories and associated risk factors. We searched PubMed, EMBASE, and Google Scholar from 2000 through September 30, 2019, for relevant studies. The study was conducted according to the PRISMA recommendations. RESULTS Thirteen cohort studies conducted in eleven high-income countries were included in our meta-analysis with the length of follow-up ranging from 3 to 18 years. Five distinct latent wheeze trajectory groups were identified: Never/Infrequent, Early-Transient, Early-Persistent, Intermediate-Onset, and Late-Onset. We found moderate-to-strong evidence that family history of asthma predicted persistent childhood wheezing among male children but with lower risk among first-born children. There was weak-to-moderate evidence for childhood atopy, male sex, short duration of breastfeeding, tobacco exposure, daycare attendance, and having siblings as risk factors for Early-Transient wheezing; except for breastfeeding, these factors were also associated with intermediate and Late-Onset wheezing with varying effect sizes in high-risk vs general population cohorts. CONCLUSIONS Our findings confirm the consistency of wheeze trajectory groups defined by onset, peak prevalence, and duration; we also suggest a common nomenclature for future trajectory studies. With the exception of the relationship between a family history of asthma and persistent childhood wheezing, commonly suspected wheeze risk factors (childhood atopy, male sex, short duration of breastfeeding, tobacco exposure, daycare attendance, and having siblings) are not trajectory-specific and have varying effects in high-risk vs general population cohorts. Delineation of time-varying risk factor effects may be critical to the specificity of wheeze trajectory group prediction to better inform prognosis and targeted early preventive intervention among at-risk children.
Collapse
Affiliation(s)
- Arthur H Owora
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Yijia Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington, IN, USA
| |
Collapse
|
18
|
Custovic A, Custovic D, Kljaić Bukvić B, Fontanella S, Haider S. Atopic phenotypes and their implication in the atopic march. Expert Rev Clin Immunol 2020; 16:873-881. [PMID: 32856959 DOI: 10.1080/1744666x.2020.1816825] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Eczema, allergic rhinitis, and asthma are traditionally considered atopic (or allergic) diseases. They are complex, multifactorial, and are caused by a variety of different mechanisms, which result in multiple heterogeneous clinical phenotypes. Atopic march is usually interpreted as the sequential development of symptoms from eczema in infancy, to asthma, and then allergic rhinitis. Areas covered: The authors reviewed the evidence on the multimorbidity of eczema, asthma, and rhinitis, and the implication of results of data-driven analyses on the concept framework of atopic march. A literature search was conducted in the PubMed and Web of Science for peer-reviewed articles published until July 2020. Application of Bayesian machine learning framework to rich phenotypic data from birth cohorts demonstrated that the postulated linear progression of symptoms (atopic march) does not capture the heterogeneity of allergic phenotypes. Expert opinion: Eczema, wheeze, and rhinitis co-exist more often than would be expected by chance, but their relationship can be best understood in a multimorbidity framework, rather than through atopic march sequence. The observation of their co-occurrence does not imply any specific relationship between them, and certainly not a progressive or causal one. It is unlikely that a sngle mechanism such as allergic sensitization underpins different multimorbidity manifestations.
Collapse
Affiliation(s)
- Adnan Custovic
- National Heart and Lung Institute, Imperial College London , London, UK
| | - Darije Custovic
- Department of Brain Sciences, Imperial College London , London, UK
| | - Blazenka Kljaić Bukvić
- Department of Pediatrics, General Hospital Dr Josip Benčević , Slavonski Brod, Croatia.,Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek , Osijek, Croatia.,Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek , Osijek, Croatia
| | - Sara Fontanella
- National Heart and Lung Institute, Imperial College London , London, UK
| | - Sadia Haider
- National Heart and Lung Institute, Imperial College London , London, UK
| |
Collapse
|
19
|
Pijnenburg MW, Fleming L. Advances in understanding and reducing the burden of severe asthma in children. THE LANCET RESPIRATORY MEDICINE 2020; 8:1032-1044. [PMID: 32910897 DOI: 10.1016/s2213-2600(20)30399-4] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/10/2020] [Accepted: 08/22/2020] [Indexed: 01/16/2023]
Abstract
Severe asthma in children is rare, accounting for only a small proportion of childhood asthma. After addressing modifiable factors such as adherence to treatment, comorbidities, and adverse exposures, children whose disease is not well controlled on high doses of medication form a heterogeneous group of severe asthma phenotypes. Over the past decade, considerable advances have been made in understanding the pathophysiology of severe therapy-resistant asthma in children. However, asthma attacks and hospital admissions are frequent and mortality is still unacceptably high. Strategies to modify the natural history of asthma, prevent severe exacerbations, and prevent lung function decline are needed. Mechanistic studies have led to the development of several biologics targeting type 2 inflammation. This growing pipeline has the potential to reduce the burden of severe asthma; however, detailed assessment and characterisation of each child with seemingly severe asthma is necessary so that the most effective and appropriate management strategy can be implemented. Risk stratification, remote monitoring, and the integration of multiple data sources could help to tailor management for the individual child with severe asthma.
Collapse
Affiliation(s)
- Mariëlle W Pijnenburg
- Department of Paediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands.
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College, London, UK
| |
Collapse
|
20
|
Kowalik K, Dai R, Safavi S, Reyna ME, Lou W, Lepine C, McDonald E, Schaap MJ, Brydges MG, Dubeau A, Boutis K, Narang I, Eiwegger T, Moraes TJ, Ratjen F, Subbarao P. Persistent ventilation inhomogeneity after an acute exacerbation in preschool children with recurrent wheezing. Pediatr Allergy Immunol 2020; 31:608-615. [PMID: 32160369 DOI: 10.1111/pai.13245] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Preschool children with recurrent wheezing suffer high morbidity. It is unclear whether objective measures of asthma control, such as pulmonary function tests (PFTs), provide additional information to the clinical assessment. METHODS We recruited children between 3 and 6 years old, with a history of recurrent wheezing in the preceding year and treated for acute wheezing exacerbation in the emergency department (ED) into an observational cohort study. Children attended two outpatient visits: the first study visit within five days of discharge from the ED and the second study visit 12 weeks after the ED visit. We performed standardized symptom score (test for respiratory and asthma control in kids (TRACK)), multiple breath washout (MBW), spirometry, and clinical assessment at both visits. RESULTS Seventy-four children, mean (standard deviation (SD)) age of 4.32 years (0.84), attended both visits. Paired FEV0.75 and lung clearance index (LCI) measurements at both time points were obtained in 37 and 34 subjects, respectively. Feasibility for all tests improved at visit 2 and was not age-dependent. At the second study visit, a third had controlled asthma based on the TRACK score, and the mean lung clearance index (LCI) improved from 9.86 to 8.31 (P = .003); however, 46% had an LCI in the abnormal range. FEV0.75 z-score improved from -1.66 to -1.17 (P = .05) but remained in the abnormal range in 24%. LCI was abnormal in more than half of the children with "well-controlled" asthma based on the TRACK score. There was no correlation between PFT measures and TRACK scores at either visit. CONCLUSIONS Lung clearance index demonstrates a persistent deficit post-exacerbation in a large proportion of preschoolers with recurrent wheezing, highlighting that symptom scores alone may not suffice for monitoring these children.
Collapse
Affiliation(s)
- Krzysztof Kowalik
- Division of Respiratory Medicine, Department of Paediatrics, Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Ruixue Dai
- Division of Respiratory Medicine, Department of Paediatrics, Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Shahideh Safavi
- Respiratory Medicine Department, Queen's Medical Centre, University of Nottingham School of Medicine, Nottingham, UK
| | - Myrtha E Reyna
- Division of Respiratory Medicine, Department of Paediatrics, Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Wendy Lou
- Dalla Lana School of Public Health, Division of Biostatistics, University of Toronto, Toronto, Canada
| | - Claire Lepine
- Division of Respiratory Medicine, Department of Paediatrics, Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Erica McDonald
- Division of Respiratory Medicine, Department of Paediatrics, Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Mirjam J Schaap
- Division of Respiratory Medicine, Department of Paediatrics, Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada.,Division of Respiratory Medicine and Allergy, Department of Pediatrics, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands
| | - May G Brydges
- Division of Respiratory Medicine, Department of Paediatrics, Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Aimee Dubeau
- Division of Respiratory Medicine, Department of Paediatrics, Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Kathy Boutis
- Division of Paediatric Emergency Medicine, Department of Paediatrics, Program in Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Indra Narang
- Division of Respiratory Medicine, Department of Paediatrics, Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Thomas Eiwegger
- Division of Immunology & Allergy, Department of Paediatrics, Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Theo J Moraes
- Division of Respiratory Medicine, Department of Paediatrics, Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Paediatrics, Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Padmaja Subbarao
- Division of Respiratory Medicine, Department of Paediatrics, Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada.,Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, Canada.,Dalla Lana School of Public Health, Division of Epidemiology, University of Toronto, Toronto, Canada
| |
Collapse
|
21
|
Distinguishing Wheezing Phenotypes from Infancy to Adolescence. A Pooled Analysis of Five Birth Cohorts. Ann Am Thorac Soc 2020; 16:868-876. [PMID: 30888842 PMCID: PMC6600832 DOI: 10.1513/annalsats.201811-837oc] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Rationale: Pooling data from multiple cohorts and extending the time frame across childhood should minimize study-specific effects, enabling better characterization of childhood wheezing. Objectives: To analyze wheezing patterns from early childhood to adolescence using combined data from five birth cohorts. Methods: We used latent class analysis to derive wheeze phenotypes among 7,719 participants from five birth cohorts with complete report of wheeze at five time periods. We tested the associations of derived phenotypes with late asthma outcomes and lung function, and investigated the uncertainty in phenotype assignment. Results: We identified five phenotypes: never/infrequent wheeze (52.1%), early onset preschool remitting (23.9%), early onset midchildhood remitting (9%), persistent (7.9%), and late-onset wheeze (7.1%). Compared with the never/infrequent wheeze, all phenotypes had higher odds of asthma and lower forced expiratory volume in 1 second and forced expiratory volume in 1 second/forced vital capacity in adolescence. The association with asthma was strongest for persistent wheeze (adjusted odds ratio, 56.54; 95% confidence interval, 43.75–73.06). We observed considerable within-class heterogeneity at the individual level, with 913 (12%) children having low membership probability (<0.60) of any phenotype. Class membership certainty was highest in persistent and never/infrequent, and lowest in late-onset wheeze (with 51% of participants having membership probabilities <0.80). Individual wheezing patterns were particularly heterogeneous in late-onset wheeze, whereas many children assigned to early onset preschool remitting class reported wheezing at later time points. Conclusions: All wheeze phenotypes had significantly diminished lung function in school-age children, suggesting that the notion that early life episodic wheeze has a benign prognosis may not be true for a proportion of transient wheezers. We observed considerable within-phenotype heterogeneity in individual wheezing patterns.
Collapse
|
22
|
Fainardi V, Santoro A, Caffarelli C. Preschool Wheezing: Trajectories and Long-Term Treatment. Front Pediatr 2020; 8:240. [PMID: 32478019 PMCID: PMC7235303 DOI: 10.3389/fped.2020.00240] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 04/20/2020] [Indexed: 12/13/2022] Open
Abstract
Wheezing is very common in infancy affecting one in three children during the first 3 years of life. Several wheeze phenotypes have been identified and most rely on temporal pattern of symptoms. Assessing the risk of asthma development is difficult. Factors predisposing to onset and persistence of wheezing such as breastfeeding, atopy, indoor allergen exposure, environmental tobacco smoke and viral infections are analyzed. Inhaled corticosteroids are recommended as first choice of controller treatment in all preschool children irrespective of phenotype, but they are particularly beneficial in terms of fewer exacerbations in atopic children. Other therapeutic options include the addition of montelukast or the intermittent use of inhaled corticosteroids. Overuse of inhaled steroids must be avoided. Therefore, adherence to treatment and correct administration of the medications need to be checked at every visit.
Collapse
Affiliation(s)
| | | | - Carlo Caffarelli
- Clinica Pediatrica, Department of Medicine and Surgery, University of Parma, Parma, Italy
| |
Collapse
|
23
|
Kenyon CC, Maltenfort MG, Hubbard RA, Schinasi LH, De Roos AJ, Henrickson SE, Bryant-Stephens TC, Forrest CB. Variability in Diagnosed Asthma in Young Children in a Large Pediatric Primary Care Network. Acad Pediatr 2020; 20:958-966. [PMID: 32044466 PMCID: PMC8628349 DOI: 10.1016/j.acap.2020.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/27/2020] [Accepted: 02/01/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Our objectives were to 1) quantify the frequency of wheezing episodes and asthma diagnosis in young children in a large pediatric primary care network and 2) assess the variability in practice-level asthma diagnosis, accounting for common asthma risk factors and comorbidities. We hypothesized that significant variability in practice-level asthma diagnosis rates would remain after adjusting for associated predictors. METHODS We generated a retrospective longitudinal birth cohort of children who visited 1 of 31 pediatric primary care practices within the first 6 months of life from 1/2005 to 12/2016. Children were observed for up to 8 years or until the end of the observation window. We used multivariable discrete time survival models to evaluate predictors of asthma diagnosis by 3-month age intervals. We compared unadjusted and adjusted proportions of children diagnosed with asthma by practice. RESULTS Of the 161,502 children in the cohort, 34,578 children (21%) received at least 1 asthma diagnosis. In multivariable modeling, male gender, minority race/ethnicity, gestational age <34 weeks, allergic rhinitis, food allergy, and prior wheezing episodes were associated with asthma diagnosis. After adjusting for variation in these predictors across practices, the cumulative incidence of asthma diagnosis by practice by age 6 years ranged from 11% to 47% (interquartile range: 24%-29%). CONCLUSIONS Across pediatric primary care practices, adjusted incidence of asthma diagnosis by age 6 years ranged widely, though variation gauged by the interquartile range was more modest. Potential sources of practice-level variation, such as differing diagnosis thresholds and labeling of different wheezing phenotypes as "asthma," should be further investigated.
Collapse
Affiliation(s)
- Chén C. Kenyon
- PolicyLab, Children’s Hospital of Philadelphia,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania
| | | | - Rebecca A. Hubbard
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania
| | - Leah H. Schinasi
- Department of Environmental and Occupational Health, Dornsife School of Public Health, Drexel University,Urban Health Collaborative, Dornsife School of Public Health, Drexel University
| | - Anneclaire J. De Roos
- Department of Environmental and Occupational Health, Dornsife School of Public Health, Drexel University,Urban Health Collaborative, Dornsife School of Public Health, Drexel University
| | - Sarah E. Henrickson
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania,Division of Allergy and Immunology, Children’s Hospital of Philadelphia and Institute for Immunology, Perelman School of Medicine, Philadelphia, PA
| | | | - Christopher B. Forrest
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania,Applied Clinical Research Center, Children’s Hospital of Philadelphia
| |
Collapse
|
24
|
Brew BK, Chiesa F, Lundholm C, Örtqvist A, Almqvist C. A modern approach to identifying and characterizing child asthma and wheeze phenotypes based on clinical data. PLoS One 2019; 14:e0227091. [PMID: 31887128 PMCID: PMC6936778 DOI: 10.1371/journal.pone.0227091] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 12/12/2019] [Indexed: 12/12/2022] Open
Abstract
‘Asthma’ is a complex disease that encapsulates a heterogeneous group of phenotypes and endotypes. Research to understand these phenotypes has previously been based on longitudinal wheeze patterns or hypothesis-driven observational criteria. The aim of this study was to use data-driven machine learning to identify asthma and wheeze phenotypes in children based on symptom and symptom history data, and, to further characterize these phenotypes. The study population included an asthma-rich population of twins in Sweden aged 9–15 years (n = 752). Latent class analysis using current and historical clinical symptom data generated asthma and wheeze phenotypes. Characterization was then performed with regression analyses using diagnostic data: lung function and immunological biomarkers, parent-reported medication use and risk-factors. The latent class analysis identified four asthma/wheeze phenotypes: early transient wheeze (15%); current wheeze/asthma (5%); mild asthma (9%), moderate asthma (10%) and a healthy phenotype (61%). All wheeze and asthma phenotypes were associated with reduced lung function and risk of hayfever compared to healthy. Children with mild and moderate asthma phenotypes were also more likely to have eczema, allergic sensitization and a family history of asthma. Furthermore, those with moderate asthma phenotype had a higher eosinophil concentration (β 0.21, 95%CI 0.12, 0.30) compared to healthy and used short-term relievers at a higher rate than children with mild asthma phenotype (RR 2.4, 95%CI 1.2–4.9). In conclusion, using a data driven approach we identified four wheeze/asthma phenotypes which were validated with further characterization as unique from one another and which can be adapted for use by the clinician or researcher.
Collapse
Affiliation(s)
- Bronwyn K. Brew
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and the School of Women and Children’s Health, University of New South Wales, Sydney, Australia
- * E-mail:
| | - Flaminia Chiesa
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- IQVIA Nordics, Stockholm, Sweden
| | - Cecilia Lundholm
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Anne Örtqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Visby Lasarett, Gotland, Sweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Pediatric Allergy and Pulmonology Unit, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
25
|
Granell R. Respiratory Phenotypes during Childhood and Early-Life Exposures. Am J Respir Crit Care Med 2019; 199:7-9. [PMID: 30095995 DOI: 10.1164/rccm.201807-1359ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Raquel Granell
- 1 Bristol Medical School University of Bristol Bristol, United Kingdom
| |
Collapse
|
26
|
Custovic A, Belgrave D, Lin L, Bakhsoliani E, Telcian AG, Solari R, Murray CS, Walton RP, Curtin J, Edwards MR, Simpson A, Rattray M, Johnston SL. Cytokine Responses to Rhinovirus and Development of Asthma, Allergic Sensitization, and Respiratory Infections during Childhood. Am J Respir Crit Care Med 2019; 197:1265-1274. [PMID: 29466680 DOI: 10.1164/rccm.201708-1762oc] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
RATIONALE Immunophenotypes of antiviral responses, and their relationship with asthma, allergy, and lower respiratory tract infections, are poorly understood. OBJECTIVES We characterized multiple cytokine responses of peripheral blood mononuclear cells to rhinovirus stimulation, and their relationship with clinical outcomes. METHODS In a population-based birth cohort, we measured 28 cytokines after stimulation with rhinovirus-16 in 307 children aged 11 years. We used machine learning to identify patterns of cytokine responses, and related these patterns to clinical outcomes, using longitudinal models. We also ascertained phytohemagglutinin-induced T-helper cell type 2 (Th2)-cytokine responses (PHA-Th2). MEASUREMENTS AND MAIN RESULTS We identified six clusters of children based on their rhinovirus-16 responses, which were differentiated by the expression of four cytokine/chemokine groups: interferon-related (IFN), proinflammatory (Inflam), Th2-chemokine (Th2-chem), and regulatory (Reg). Clusters differed in their clinical characteristics. Children with an IFNmodInflamhighestTh2-chemhighestReghighest rhinovirus-16-induced pattern had a PHA-Th2low response, and a very low asthma risk (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.01-0.81; P = 0.03). Two clusters had a high risk of asthma and allergic sensitization, but with different trajectories from infancy to adolescence. The IFNlowestInflamhighTh2-chemlowRegmod cluster exhibited a PHA-Th2lowest response and was associated with early-onset asthma and sensitization, and the highest risk of asthma exacerbations (OR, 1.37; 95% CI, 1.07-1.76; P = 0.014) and lower respiratory tract infection hospitalizations (OR, 2.40; 95% CI, 1.26-4.58; P = 0.008) throughout childhood. In contrast, the IFNhighestInflammodTh2-chemmodReghigh cluster with a rhinovirus-16-cytokine pattern was characterized by a PHA-Th2highest response, and a low prevalence of asthma/sensitization in infancy that increased sharply to become the highest among all clusters by adolescence (but with a low risk of asthma exacerbations). CONCLUSIONS Early-onset troublesome asthma with early-life sensitization, later-onset milder allergic asthma, and disease protection are each associated with different patterns of rhinovirus-induced immune responses.
Collapse
Affiliation(s)
- Adnan Custovic
- 1 Section of Paediatrics, Department of Medicine, Imperial College London, London, United Kingdom.,2 MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | - Danielle Belgrave
- 1 Section of Paediatrics, Department of Medicine, Imperial College London, London, United Kingdom
| | - Lijing Lin
- 3 Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Eteri Bakhsoliani
- 2 MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.,4 COPD and Asthma Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
| | - Aurica G Telcian
- 2 MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.,4 COPD and Asthma Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
| | - Roberto Solari
- 2 MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.,4 COPD and Asthma Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
| | - Clare S Murray
- 5 Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre, University of Manchester and University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Ross P Walton
- 2 MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.,4 COPD and Asthma Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
| | - John Curtin
- 5 Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre, University of Manchester and University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Michael R Edwards
- 2 MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.,4 COPD and Asthma Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
| | - Angela Simpson
- 5 Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre, University of Manchester and University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Magnus Rattray
- 3 Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Sebastian L Johnston
- 2 MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.,4 COPD and Asthma Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
| |
Collapse
|
27
|
Oksel C, Granell R, Mahmoud O, Custovic A, Henderson AJ. Causes of variability in latent phenotypes of childhood wheeze. J Allergy Clin Immunol 2019; 143:1783-1790.e11. [PMID: 30528616 PMCID: PMC6505513 DOI: 10.1016/j.jaci.2018.10.059] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/29/2018] [Accepted: 10/12/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Latent class analysis (LCA) has been used extensively to identify (latent) phenotypes of childhood wheezing. However, the number and trajectory of discovered phenotypes differed substantially between studies. OBJECTIVE We sought to investigate sources of variability affecting the classification of phenotypes, identify key time points for data collection to understand wheeze heterogeneity, and ascertain the association of childhood wheeze phenotypes with asthma and lung function in adulthood. METHODS We used LCA to derive wheeze phenotypes among 3167 participants in the ALSPAC cohort who had complete information on current wheeze recorded at 14 time points from birth to age 16½ years. We examined the effects of sample size and data collection age and intervals on the results and identified time points. We examined the associations of derived phenotypes with asthma and lung function at age 23 to 24 years. RESULTS A relatively large sample size (>2000) underestimated the number of phenotypes under some conditions (eg, number of time points <11). Increasing the number of data points resulted in an increase in the optimal number of phenotypes, but an identical number of randomly selected follow-up points led to different solutions. A variable selection algorithm identified 8 informative time points (months 18, 42, 57, 81, 91, 140, 157, and 166). The proportion of asthmatic patients at age 23 to 24 years differed between phenotypes, whereas lung function was lower among persistent wheezers. CONCLUSIONS Sample size, frequency, and timing of data collection have a major influence on the number and type of wheeze phenotypes identified by using LCA in longitudinal data.
Collapse
Affiliation(s)
- Ceyda Oksel
- Section of Paediatrics, Department of Medicine, Imperial College London, London, United Kingdom
| | - Raquel Granell
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Osama Mahmoud
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Adnan Custovic
- Section of Paediatrics, Department of Medicine, Imperial College London, London, United Kingdom.
| | - A John Henderson
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| |
Collapse
|
28
|
Bougas N, Just J, Beydon N, De Blic J, Gabet S, Lezmi G, Amat F, Rancière F, Momas I. Unsupervised trajectories of respiratory/allergic symptoms throughout childhood in the PARIS cohort. Pediatr Allergy Immunol 2019; 30:315-324. [PMID: 30681195 DOI: 10.1111/pai.13027] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 12/23/2018] [Accepted: 12/24/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Natural course and co-occurrence of asthma, eczema, and allergic rhinitis through childhood are still not fully documented. We aim to identify and characterize profiles based on the time course, severity, and apparent triggers of respiratory/allergy symptoms in school-aged children. METHODS Data on occurrence, severity, and triggers of asthma, rhinitis, and dermatitis symptoms were collected annually during the follow-up of the PARIS birth cohort. Children with similar symptom trajectories until 8-9 years were grouped into profiles using multidimensional (all symptoms considered simultaneously) cluster analysis. Associations between profiles and different health outcomes were analyzed using logistic or linear regression models. RESULTS Six distinct symptomatic profiles were identified. A profile was defined by persistent dermatitis symptoms, associated with sensitization to food and aeroallergens. Two profiles were characterized by wheezing: one with early transient wheezing and the other with persistent wheezing related to doctor-diagnosed asthma, airway obstruction, and perennial aeroallergen sensitization. Three profiles were characterized by rhinitis symptoms: one non-allergic and two allergic, either with persistent rhinitis symptoms related to allergic multimorbidity and sensitization to perennial aeroallergens, or with late-onset symptoms, related to both pollen and perennial aeroallergens sensitization as well as low lung function. CONCLUSION This study brings further insights into the developmental profiles of respiratory/allergic outcomes from birth to school age. The identified profiles clearly differed regarding objective features such as diagnosed morbidity, sensitization, or lung function measurements, thus highlighting their biologic and clinical relevance. Allergic rhinitis profiles deserve particular attention, since they were likely to be involved in multimorbidity patterns.
Collapse
Affiliation(s)
- Nicolas Bougas
- INSERM UMR 1153 - CRESS, HERA (Health Environmental Risk Assessment) research unit, Université Paris Descartes - Sorbonne Paris Cité, Paris, France
| | - Jocelyne Just
- Service d'Allergologie Pédiatrique, AP-HP, Hôpital d'Enfants Armand-Trousseau, Paris, France.,Université Paris Pierre et Marie Curie, Paris, France
| | - Nicole Beydon
- Unité Fonctionnelle de Physiologie-Explorations Fonctionnelles Respiratoires (EFR), AP-HP, Hôpital Armand-Trousseau, Paris, France
| | - Jacques De Blic
- Service de Pneumologie et d'Allergologie Pédiatriques, AP-HP, Hôpital Necker-Enfants Malades, Paris, France.,Université Paris Descartes - Sorbonne Paris Cité, Paris, France
| | - Stephan Gabet
- INSERM UMR 1153 - CRESS, HERA (Health Environmental Risk Assessment) research unit, Université Paris Descartes - Sorbonne Paris Cité, Paris, France
| | - Guillaume Lezmi
- Service de Pneumologie et d'Allergologie Pédiatriques, AP-HP, Hôpital Necker-Enfants Malades, Paris, France.,Université Paris Descartes - Sorbonne Paris Cité, Paris, France
| | - Flore Amat
- Service d'Allergologie Pédiatrique, AP-HP, Hôpital d'Enfants Armand-Trousseau, Paris, France.,Université Paris Pierre et Marie Curie, Paris, France
| | - Fanny Rancière
- INSERM UMR 1153 - CRESS, HERA (Health Environmental Risk Assessment) research unit, Université Paris Descartes - Sorbonne Paris Cité, Paris, France
| | - Isabelle Momas
- INSERM UMR 1153 - CRESS, HERA (Health Environmental Risk Assessment) research unit, Université Paris Descartes - Sorbonne Paris Cité, Paris, France.,Cellule Cohorte, Mairie de Paris, Direction de l'Action Sociale de l'Enfance et de la Santé, Paris, France
| |
Collapse
|
29
|
Development of allergic sensitization and its relevance to paediatric asthma. Curr Opin Allergy Clin Immunol 2019; 18:109-116. [PMID: 29389732 DOI: 10.1097/aci.0000000000000430] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the recent evidence on the distinct atopic phenotypes and their relationship with childhood asthma. We start by considering definitions and phenotypic classification of atopy and then review evidence on its association with asthma in children. RECENT FINDINGS It is now well recognized that both asthma and atopy are complex entities encompassing various different sub-groups that also differ in the way they interconnect. The lack of gold standards for diagnostic markers of atopy and asthma further adds to the existing complexity over diagnostic accuracy and definitions. Although recent statistical phenotyping studies contributed significantly to our understanding of these heterogeneous disorders, translating these findings into meaningful information and effective therapies requires further work on understanding underpinning biological mechanisms. SUMMARY The disaggregation of allergic sensitization may help predict how the allergic disease is likely to progress. One of the important questions is how best to incorporate tests for the assessment of allergic sensitization into diagnostic algorithms for asthma, both in terms of confirming asthma diagnosis, and the assessment of future risk.
Collapse
|
30
|
Fleming L, Heaney L. Severe Asthma-Perspectives From Adult and Pediatric Pulmonology. Front Pediatr 2019; 7:389. [PMID: 31649906 PMCID: PMC6794347 DOI: 10.3389/fped.2019.00389] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 09/09/2019] [Indexed: 12/11/2022] Open
Abstract
Both adults and children with severe asthma represent a small proportion of the asthma population; however, they consume disproportionate resources. For both groups it is important to confirm the diagnosis of severe asthma and ensure that modifiable factors such as adherence have, as far as possible, been addressed. Most children can be controlled on inhaled corticosteroids and long term oral corticosteroid use is rare, in contrast to adults where steroid related morbidity accounts for a large proportion of the costs of severe asthma. Atopic sensitization is very common in children with severe asthma as are other atopic conditions such as allergic rhinitis and hay fever which can impact on asthma control. In adults, the role of allergic driven disease, even in those with co-existent evidence of sensitization, is unclear. There is currently an exciting pipeline of novel biologicals, particularly directed at Type 2 inflammation, which afford the possibility of improved asthma control and reduced treatment side effects for people with asthma. However, not all drugs will work for all patients and accurate phenotyping is essential. In adults the terms T2 high and T2 low asthma have been coined to describe groups of patients based on the presence/absence of eosinophilic inflammation and T-helper 2 (TH2) cytokines. Bronchoscopic studies in children with severe asthma have demonstrated that these children are predominantly eosinophilic but the cytokine patterns do not fit the T2 high paradigm suggesting other steroid resistant pathways are driving the eosinophilic inflammation. It remains to be seen whether treatments developed for adult severe asthma will be effective in children and which biomarkers will predict response.
Collapse
Affiliation(s)
- Louise Fleming
- National Heart and Lung Institute, Imperial College, London and Royal Brompton Hospital, London, United Kingdom
| | - Liam Heaney
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Institute for Health Sciences, Queens University Belfast, Belfast, United Kingdom
| |
Collapse
|
31
|
Dharmage SC, Perret JL, Custovic A. Epidemiology of Asthma in Children and Adults. Front Pediatr 2019; 7:246. [PMID: 31275909 PMCID: PMC6591438 DOI: 10.3389/fped.2019.00246] [Citation(s) in RCA: 503] [Impact Index Per Article: 100.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/29/2019] [Indexed: 11/23/2022] Open
Abstract
Asthma is a globally significant non-communicable disease with major public health consequences for both children and adults, including high morbidity, and mortality in severe cases. We have summarized the evidence on asthma trends, environmental determinants, and long-term impacts while comparing these epidemiological features across childhood asthma and adult asthma. While asthma incidence and prevalence are higher in children, morbidity, and mortality are higher in adults. Childhood asthma is more common in boys while adult asthma is more common in women, and the reversal of this sex difference in prevalence occurs around puberty suggesting sex hormones may play a role in the etiology of asthma. The global epidemic of asthma that has been observed in both children and adults is still continuing, especially in low to middle income countries, although it has subsided in some developed countries. As a heterogeneous disease, distinct asthma phenotypes, and endotypes need to be adequately characterized to develop more accurate and meaningful definitions for use in research and clinical settings. This may be facilitated by new clustering techniques such as latent class analysis, and computational phenotyping methods are being developed to retrieve information from electronic health records using natural language processing (NLP) algorithms to assist in the early diagnosis of asthma. While some important environmental determinants that trigger asthma are well-established, more work is needed to define the role of environmental exposures in the development of asthma in both children and adults. There is increasing evidence that investigation into possible gene-by-environment and environment-by-environment interactions may help to better uncover the determinants of asthma. Therefore, there is an urgent need to further investigate the interrelationship between environmental and genetic determinants to identify high risk groups and key modifiable exposures. For children, asthma may impair airway development and reduce maximally attained lung function, and these lung function deficits may persist into adulthood without additional progressive loss. Adult asthma may accelerate lung function decline and increase the risk of fixed airflow obstruction, with the effect of early onset asthma being greater than late onset asthma. Therefore, in managing asthma, our focus going forward should be firmly on improving not only short-term symptoms, but also the long-term respiratory and other health outcomes.
Collapse
Affiliation(s)
- Shyamali C Dharmage
- Allergy and Lung Health Unit, School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Jennifer L Perret
- Allergy and Lung Health Unit, School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia.,Institute for Breathing and Sleep, Melbourne, VIC, Australia
| | - Adnan Custovic
- Department of Paediatrics, Imperial College London, London, United Kingdom
| |
Collapse
|
32
|
Tang HH, Teo SM, Belgrave DC, Evans MD, Jackson DJ, Brozynska M, Kusel MM, Johnston SL, Gern JE, Lemanske RF, Simpson A, Custovic A, Sly PD, Holt PG, Holt KE, Inouye M. Trajectories of childhood immune development and respiratory health relevant to asthma and allergy. eLife 2018; 7:35856. [PMID: 30320550 PMCID: PMC6221547 DOI: 10.7554/elife.35856] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 10/05/2018] [Indexed: 12/28/2022] Open
Abstract
Events in early life contribute to subsequent risk of asthma; however, the causes and trajectories of childhood wheeze are heterogeneous and do not always result in asthma. Similarly, not all atopic individuals develop wheeze, and vice versa. The reasons for these differences are unclear. Using unsupervised model-based cluster analysis, we identified latent clusters within a prospective birth cohort with deep immunological and respiratory phenotyping. We characterised each cluster in terms of immunological profile and disease risk, and replicated our results in external cohorts from the UK and USA. We discovered three distinct trajectories, one of which is a high-risk ‘atopic’ cluster with increased propensity for allergic diseases throughout childhood. Atopy contributes varyingly to later wheeze depending on cluster membership. Our findings demonstrate the utility of unsupervised analysis in elucidating heterogeneity in asthma pathogenesis and provide a foundation for improving management and prevention of childhood asthma. Asthma causes wheezy and troubled breathing, and can be life-threatening. Scientists and doctors understand that asthma begins in early childhood. Chest infections, exposure to bacteria, viruses, and allergies may cause or trigger asthma. One person with asthma may not have the same origins as another. But it is not yet clear how various triggers may interact to trigger or exacerbate asthma. To disentangle how these factors contribute to asthma, experts have tried to group people with asthma into subgroups. Unfortunately, the groups often vary from expert to expert. Now, some scientists are using computers to sort patients with asthma. The scientists let the computers decide the best criteria for sorting patients. This way the machines may identify patterns that are not obvious to humans. Using this computer-based approach, Tang et al. sorted Australian children with asthma into 3 groups based on their early life allergies and respiratory health. One group has high-risk asthma with frequent chest infections and strong allergic responses. The other two groups are low-risk, but they respond differently to allergy and infection. Common tests used by doctors to diagnose patients with allergy or asthma may not work the same with all three groups. The bacteria found in the nose influence the risk of asthma, even in patients who are well, and the way this occurs varies by group. Similar groups were also found among children with asthma in the United States and the United Kingdom. Learning more about subgroups of patients with asthma may help other scientists and doctors design better ways to diagnose, treat, or prevent asthma. Working together with scientists around the world to determine how to best describe subgroups of people according to asthma type and risk is a critical step in the process. Tang et al. hope other scientist will test whether these three groups are also found in people from other parts of the world.
Collapse
Affiliation(s)
- Howard Hf Tang
- Cambridge Baker Systems Genomics Initiative, Baker Heart and Diabetes Institute, Victoria, Australia.,School of BioSciences, The University of Melbourne, Victoria, Australia
| | - Shu Mei Teo
- Cambridge Baker Systems Genomics Initiative, Baker Heart and Diabetes Institute, Victoria, Australia.,Cambridge Baker Systems Genomics Initiative, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | | | - Michael D Evans
- Cambridge Baker Systems Genomics Initiative, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.,University of Wisconsin School of Medicine and Public Health, Madison, United States
| | - Daniel J Jackson
- University of Wisconsin School of Medicine and Public Health, Madison, United States
| | - Marta Brozynska
- Cambridge Baker Systems Genomics Initiative, Baker Heart and Diabetes Institute, Victoria, Australia.,Department of Paediatrics, Imperial College London, London, United Kingdom
| | - Merci Mh Kusel
- Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Sebastian L Johnston
- Airway Disease Infection Section, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James E Gern
- University of Wisconsin School of Medicine and Public Health, Madison, United States
| | - Robert F Lemanske
- University of Wisconsin School of Medicine and Public Health, Madison, United States
| | - Angela Simpson
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, United Kingdom
| | - Adnan Custovic
- Department of Paediatrics, Imperial College London, London, United Kingdom
| | - Peter D Sly
- Telethon Kids Institute, University of Western Australia, Perth, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Patrick G Holt
- Telethon Kids Institute, University of Western Australia, Perth, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Kathryn E Holt
- Bio21 Molecular Science and Biotechnology Institute, The University of Melbourne, Victoria, Australia.,The London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Michael Inouye
- Cambridge Baker Systems Genomics Initiative, Baker Heart and Diabetes Institute, Victoria, Australia.,Cambridge Baker Systems Genomics Initiative, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.,The Alan Turing Institute, London, United Kingdom
| |
Collapse
|
33
|
Howard R, Belgrave D, Papastamoulis P, Simpson A, Rattray M, Custovic A. Evolution of IgE responses to multiple allergen components throughout childhood. J Allergy Clin Immunol 2018; 142:1322-1330. [PMID: 29428391 PMCID: PMC6170973 DOI: 10.1016/j.jaci.2017.11.064] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 11/04/2017] [Accepted: 11/13/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is a paucity of information about longitudinal patterns of IgE responses to allergenic proteins (components) from multiple sources. OBJECTIVES This study sought to investigate temporal patterns of component-specific IgE responses from infancy to adolescence, and their relationship with allergic diseases. METHODS In a population-based birth cohort, we measured IgE to 112 components at 6 follow-ups during childhood. We used a Bayesian method to discover cross-sectional sensitization patterns and their longitudinal trajectories, and we related these patterns to asthma and rhinitis in adolescence. RESULTS We identified 1 sensitization cluster at age 1, 3 at age 3, 4 at ages 5 and 8, 5 at age 11, and 6 at age 16 years. "Broad" cluster was the only cluster present at every follow-up, comprising components from multiple sources. "Dust mite" cluster formed at age 3 years and remained unchanged to adolescence. At age 3 years, a single-component "Grass" cluster emerged, which at age 5 years absorbed additional grass components and Fel d 1 to form the "Grass/cat" cluster. Two new clusters formed at age 11 years: "Cat" cluster and "PR-10/profilin" (which divided at age 16 years into "PR-10" and "Profilin"). The strongest contemporaneous associate of asthma at age 16 years was sensitization to dust mite cluster (odds ratio: 2.6; 95% CI: 1.2-6.1; P < .05), but the strongest early life predictor of subsequent asthma was sensitization to grass/cat cluster (odds ratio: 3.5; 95% CI: 1.6-7.4; P < .01). CONCLUSIONS We describe the architecture of the evolution of IgE responses to multiple allergen components throughout childhood, which may facilitate development of better diagnostic and prognostic biomarkers for allergic diseases.
Collapse
Affiliation(s)
- Rebecca Howard
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Danielle Belgrave
- Section of Paediatrics, Department of Medicine, Imperial College London, London, United Kingdom
| | - Panagiotis Papastamoulis
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Angela Simpson
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester and University Hospital of South Manchester, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Magnus Rattray
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Adnan Custovic
- Section of Paediatrics, Department of Medicine, Imperial College London, London, United Kingdom.
| |
Collapse
|
34
|
Abstract
SNP in the vitamin D receptor (VDR) gene is associated with risk of lower respiratory infections. The influence of genetic variation in the vitamin D pathway resulting in susceptibility to upper respiratory infections (URI) has not been investigated. We evaluated the influence of thirty-three SNP in eleven vitamin D pathway genes (DBP, DHCR7, RXRA, CYP2R1, CYP27B1, CYP24A1, CYP3A4, CYP27A1, LRP2, CUBN and VDR) resulting in URI risk in 725 adults in London, UK, using an additive model with adjustment for potential confounders and correction for multiple comparisons. Significant associations in this cohort were investigated in a validation cohort of 737 children in Manchester, UK. In all, three SNP in VDR (rs4334089, rs11568820 and rs7970314) and one SNP in CYP3A4 (rs2740574) were associated with risk of URI in the discovery cohort after adjusting for potential confounders and correcting for multiple comparisons (adjusted incidence rate ratio per additional minor allele ≥1·15, P for trend ≤0·030). This association was replicated for rs4334089 in the validation cohort (P for trend=0·048) but not for rs11568820, rs7970314 or rs2740574. Carriage of the minor allele of the rs4334089 SNP in VDR was associated with increased susceptibility to URI in children and adult cohorts in the United Kingdom.
Collapse
|
35
|
Xepapadaki P, Bachert C, Finotto S, Jartti T, Konstantinou GN, Kiefer A, Kowalski M, Lewandowska-Polak A, Lukkarinen H, Roumpedaki E, Sobanska A, Sintobin I, Vuorinen T, Zhang N, Zimmermann T, Papadopoulos NG. Contribution of repeated infections in asthma persistence from preschool to school age: Design and characteristics of the PreDicta cohort. Pediatr Allergy Immunol 2018. [PMID: 29512854 DOI: 10.1111/pai.12881] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The PreDicta cohort was designed to prospectively evaluate wheeze/asthma persistence in preschoolers in association with viral/microbial exposures and immunological responses. We present the cohort design and demographic/disease characteristics and evaluate unsupervised and predefined phenotypic subgroups at inclusion. METHODS PreDicta is a 2-year prospective study conducted in five European regions, including children 4-6 years with a diagnosis of asthma as cases and healthy age-matched controls. At baseline, detailed information on demographics, asthma and allergy-related disease activity, exposures, and lifestyle were recorded. Lung function, airway inflammation, and immune responses were also assessed. Power analysis confirmed that the cohort is adequate to answer the initial hypothesis. RESULTS A total of 167 asthmatic children (102 males) and 66 healthy controls (30 males) were included. Groups were homogeneous in respect to most baseline characteristics, with the exception of male gender in cases (61%) and exposure to tobacco smoke. Comorbidities and number and duration of infections were significantly higher in asthmatics than controls. 55.7% of asthmatic children had at least one positive skin prick test to aeroallergens (controls: 33.3%, P = .002). Spirometric and exhaled nitric oxide values were within normal limits; only baseline FEV0.5 and FEV1 reversibility values were significantly different between groups. Viral infections were the most common triggers (89.2%) independent of severity, control, or atopy; however, overlapping phenotypes were also common. Severity and control clustered together in an unsupervised analysis, separating moderate from mild disease. CONCLUSIONS The PreDicta cohort presented no differences in non-asthma related measures; however, it is well balanced regarding key phenotypic characteristics representative of "preschool asthma".
Collapse
Affiliation(s)
- Paraskevi Xepapadaki
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Claus Bachert
- Upper Airway Research Laboratory, Ghent University Hospital, Ghent, Belgium
| | - Susetta Finotto
- Department of Molecular Pneumology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Tuomas Jartti
- Department of Pediatrics, Turku University Hospital and University of Turku, Turku, Finland
| | - George N Konstantinou
- Department of Allergy and Clinical Immunology, 424 General Military Training Hospital, Thessaloniki, Greece
| | - Alexander Kiefer
- Department of Pediatrics and Adolescent Medicine, Department of Allergy and Pneumology, Children's Hospital, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Marek Kowalski
- Department of Immunology, Rheumatology and Allergy, Central University Hospital, Lodz, Poland
| | - Anna Lewandowska-Polak
- Department of Immunology, Rheumatology and Allergy, Central University Hospital, Lodz, Poland.,Department of Rheumatology, Medical University of Lodz, Lodz, Poland
| | - Heikki Lukkarinen
- Department of Pediatrics, Turku University Hospital and University of Turku, Turku, Finland
| | - Eirini Roumpedaki
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Anna Sobanska
- Department of Immunology, Rheumatology and Allergy, Central University Hospital, Lodz, Poland
| | - Ina Sintobin
- Upper Airway Research Laboratory, Ghent University Hospital, Ghent, Belgium
| | - Tytti Vuorinen
- Department of Clinical Virology, Turku University Hospital, Department of Virology, Turku University, Turku, Finland
| | - Nan Zhang
- Upper Airway Research Laboratory, Ghent University Hospital, Ghent, Belgium
| | - Theodor Zimmermann
- Department of Pediatrics and Adolescent Medicine, Department of Allergy and Pneumology, Children's Hospital, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Nikolaos G Papadopoulos
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece.,Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, UK
| |
Collapse
|
36
|
Lezmi G, Deschildre A, Abou Taam R, Fayon M, Blanchon S, Troussier F, Mallinger P, Mahut B, Gosset P, de Blic J. Remodelling and inflammation in preschoolers with severe recurrent wheeze and asthma outcome at school age. Clin Exp Allergy 2018; 48:806-813. [PMID: 29603800 DOI: 10.1111/cea.13143] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 02/24/2018] [Accepted: 03/03/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND The influence of airway remodelling and inflammation in preschoolers with severe recurrent wheeze on asthma outcomes is poorly understood. OBJECTIVE To assess their association with asthma symptoms and lung function at school age. METHODS Preschoolers (38.4 months) initially investigated with bronchial biopsies were re-assessed for asthma symptoms and lung function at school age. RESULTS Thirty-six of 49 preschoolers (73.5%) were assessed at 10.9 years. Twenty-six (72.2%) had persistent asthma. Submucosal eosinophil counts were higher in children with severe exacerbations at school age than in those without (16/0.1 mm2 [11.2-30.4] vs 8/0.1 mm2 [2.4-17.6], P = .02), and correlated with the number of severe exacerbations (P = .04, r = .35). Submucosal neutrophil counts correlated with FEV1/FVC (P < .01, r = .47) and FEF25-75% predicted (P = .02, r = .43). Airway smooth muscle (ASM) area correlated with FEV1/FVC (P < .01, r = .51). Vessel numbers negatively correlated with FEV1% predicted and FEV1/FVC (P = .03, r = -.42; P = .04, r = -.41; respectively) and FEF25-75% predicted (P = .02, r = -.46). CONCLUSION Eosinophilic inflammation in preschoolers with severe recurrent wheeze might be predictive of future severe exacerbations, neutrophilia might be associated with better lung function. Changes in ASM and vascularity might affect lung function at school age.
Collapse
Affiliation(s)
- G Lezmi
- Service de Pneumologie et Allergologie Pédiatriques, Hôpital Universitaire Necker-Enfants Malades, Paris, France.,Université Paris Descartes, Paris, France
| | - A Deschildre
- Unité de Pneumologie-Allergologie Pédiatrique, Clinique de Pédiatrie Jeanne de Flandre, CHRU de Lille, Université Nord de France, Lille, France
| | - R Abou Taam
- Service de Pneumologie et Allergologie Pédiatriques, Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - M Fayon
- Centre de Recherche Cardio-thoracique de Bordeaux, Université de Bordeaux, Bordeaux, France.,CHU de Bordeaux, Centre d'Investigation Clinique (CIC 1401), Bordeaux, France
| | - S Blanchon
- Unité de Pneumologie et Allergologie Pédiatrique, Centre de Compétences des Maladies Respiratoires Rares, Hôpitaux Universitaire de Toulouse, Toulouse, France
| | - F Troussier
- Centre de Ressources et de Compétences en Mucoviscidose Enfants, Service de Pédiatrie, Centre Hospitalier Universitaire, Angers, France
| | - P Mallinger
- Cabinet de Pneumologie et d'Allergologie des Sardières, Bourg-en-Bresse, France
| | - B Mahut
- Cabinet La Berma, Antony, France
| | - P Gosset
- Centre d'Infection et d'Immunité de Lille, Institut Pasteur de Lille, Lille, France.,Centre National de la Recherche Scientifique, Lille, France.,Institut National de la Santé et de la Recherche Médicale, Lille, France.,Institut Fédératif de la Recherche 142, Lille, France
| | - J de Blic
- Service de Pneumologie et Allergologie Pédiatriques, Hôpital Universitaire Necker-Enfants Malades, Paris, France.,Université Paris Descartes, Paris, France
| |
Collapse
|
37
|
Kim BS, Lee E, Lee MJ, Kang MJ, Yoon J, Cho HJ, Park J, Won S, Lee SY, Hong SJ. Different functional genes of upper airway microbiome associated with natural course of childhood asthma. Allergy 2018; 73:644-652. [PMID: 29052232 DOI: 10.1111/all.13331] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Microbial colonization of the airway plays a role in the pathogenesis of asthma; however, the effect of the upper airway microbiome on childhood asthma is not fully understood. We analyzed the metagenome of airway microbiome to understand the associated role of upper airway microbiome with the natural course of childhood asthma. METHODS Nasopharyngeal swabs were collected from children with asthma, those in asthma remission, and control groups. High-throughput sequencing was used to examine the structure and functional dynamics of the airway microbiome with respect to asthma phenotypes. RESULTS The composition of microbiota differed among healthy control, asthma, and remission groups. The relative abundance of Streptococcus was negatively associated with FEV1% predicted (P = .023) and that of Staphylococcus was negatively associated with methacholine PC20 (P = .013). Genes related to arachidonic acid metabolites, lysine residues, and glycosaminoglycans in the microbiome could be associated with airway inflammation. In particular, genes related to synthesis of anti-inflammatory prostaglandin E2 (PGE2 ) were not detected from the airway microbiome in the asthma group. CONCLUSIONS These data suggest that alterations in the composition and function of the upper airway microbiome could be related with the natural course of asthma in children.
Collapse
Affiliation(s)
- B.-S. Kim
- Department of Life Science; Multidisciplinary Genome Institute; Hallym University; Chuncheon Korea
| | - E. Lee
- Department of Pediatrics; Chonnam National University Hospital; Gwangju Korea
| | - M.-J. Lee
- Department of Life Science; Multidisciplinary Genome Institute; Hallym University; Chuncheon Korea
| | - M.-J. Kang
- Asan Institute for Life Science; University of Ulsan College of Medicine; Seoul Korea
| | - J. Yoon
- Department of Pediatrics; Childhood Asthma Atopy Center; Environmental Health Center; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - H.-J. Cho
- Department of Pediatrics; Childhood Asthma Atopy Center; Environmental Health Center; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - J. Park
- Interdisciplinary Program of Bioinformatics; Seoul National University; Seoul Korea
| | - S. Won
- Interdisciplinary Program of Bioinformatics; Seoul National University; Seoul Korea
- Department of Public Health Science; Seoul National University; Seoul Korea
- Institute of Health and Environment; Seoul National University; Seoul Korea
| | - S. Y. Lee
- Department of Pediatrics; Childhood Asthma Atopy Center; Environmental Health Center; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - S. J. Hong
- Department of Pediatrics; Childhood Asthma Atopy Center; Environmental Health Center; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| |
Collapse
|
38
|
Griffiths LJ, Lyons RA, Bandyopadhyay A, Tingay KS, Walton S, Cortina-Borja M, Akbari A, Bedford H, Dezateux C. Childhood asthma prevalence: cross-sectional record linkage study comparing parent-reported wheeze with general practitioner-recorded asthma diagnoses from primary care electronic health records in Wales. BMJ Open Respir Res 2018; 5:e000260. [PMID: 29333271 PMCID: PMC5759709 DOI: 10.1136/bmjresp-2017-000260] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/14/2017] [Indexed: 12/02/2022] Open
Abstract
Introduction Electronic health records (EHRs) are increasingly used to estimate the prevalence of childhood asthma. The relation of these estimates to those obtained from parent-reported wheezing suggestive of asthma is unclear. We hypothesised that parent-reported wheezing would be more prevalent than general practitioner (GP)-recorded asthma diagnoses in preschool-aged children. Methods 1529 of 1840 (83%) Millennium Cohort Study children registered with GPs in the Welsh Secure Anonymised Information Linkage databank were linked. Prevalences of parent-reported wheezing and GP-recorded asthma diagnoses in the previous 12 months were estimated, respectively, from parent report at ages 3, 5, 7 and 11 years, and from Read codes for asthma diagnoses and prescriptions based on GP EHRs over the same time period. Prevalences were weighted to account for clustered survey design and non-response. Cohen’s kappa statistics were used to assess agreement. Results Parent-reported wheezing was more prevalent than GP-recorded asthma diagnoses at 3 and 5 years. Both diminished with age: by age 11, prevalences of parent-reported wheezing and GP-recorded asthma diagnosis were 12.9% (95% CI 10.6 to 15.4) and 10.9% (8.8 to 13.3), respectively (difference: 2% (−0.5 to 4.5)). Other GP-recorded respiratory diagnoses accounted for 45.7% (95% CI 37.7 to 53.9) and 44.8% (33.9 to 56.2) of the excess in parent-reported wheezing at ages 3 and 5 years, respectively. Conclusion Parent-reported wheezing is more prevalent than GP-recorded asthma diagnoses in the preschool years, and this difference diminishes in primary school-aged children. Further research is needed to evaluate the implications of these differences for the characterisation of longitudinal childhood asthma phenotypes from EHRs.
Collapse
Affiliation(s)
- Lucy J Griffiths
- Life Course Epidemiology and Biostatistics, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Ronan A Lyons
- Farr Institute, Swansea University Medical School, Swansea, UK
| | | | - Karen S Tingay
- Farr Institute, Swansea University Medical School, Swansea, UK
| | - Suzanne Walton
- Life Course Epidemiology and Biostatistics, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Mario Cortina-Borja
- Clinical Epidemiology, Nutrition and Biostatistics, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Ashley Akbari
- Farr Institute, Swansea University Medical School, Swansea, UK
| | - Helen Bedford
- Life Course Epidemiology and Biostatistics, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Carol Dezateux
- Life Course Epidemiology and Biostatistics, UCL Great Ormond Street Institute of Child Health, London, UK.,Centre for Primary Care and Public Health, Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK
| |
Collapse
|
39
|
Deliu M, Yavuz TS, Sperrin M, Belgrave D, Sahiner UM, Sackesen C, Kalayci O, Custovic A. Features of asthma which provide meaningful insights for understanding the disease heterogeneity. Clin Exp Allergy 2018; 48:39-47. [PMID: 28833810 PMCID: PMC5763358 DOI: 10.1111/cea.13014] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 07/31/2017] [Accepted: 08/15/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Data-driven methods such as hierarchical clustering (HC) and principal component analysis (PCA) have been used to identify asthma subtypes, with inconsistent results. OBJECTIVE To develop a framework for the discovery of stable and clinically meaningful asthma subtypes. METHODS We performed HC in a rich data set from 613 asthmatic children, using 45 clinical variables (Model 1), and after PCA dimensionality reduction (Model 2). Clinical experts then identified a set of asthma features/domains which informed clusters in the two analyses. In Model 3, we reclustered the data using these features to ascertain whether this improved the discovery process. RESULTS Cluster stability was poor in Models 1 and 2. Clinical experts highlighted four asthma features/domains which differentiated the clusters in two models: age of onset, allergic sensitization, severity, and recent exacerbations. In Model 3 (HC using these four features), cluster stability improved substantially. The cluster assignment changed, providing more clinically interpretable results. In a 5-cluster model, we labelled the clusters as: "Difficult asthma" (n = 132); "Early-onset mild atopic" (n = 210); "Early-onset mild non-atopic: (n = 153); "Late-onset" (n = 105); and "Exacerbation-prone asthma" (n = 13). Multinomial regression demonstrated that lung function was significantly diminished among children with "Difficult asthma"; blood eosinophilia was a significant feature of "Difficult," "Early-onset mild atopic," and "Late-onset asthma." Children with moderate-to-severe asthma were present in each cluster. CONCLUSIONS AND CLINICAL RELEVANCE An integrative approach of blending the data with clinical expert domain knowledge identified four features, which may be informative for ascertaining asthma endotypes. These findings suggest that variables which are key determinants of asthma presence, severity, or control may not be the most informative for determining asthma subtypes. Our results indicate that exacerbation-prone asthma may be a separate asthma endotype and that severe asthma is not a single entity, but an extreme end of the spectrum of several different asthma endotypes.
Collapse
Affiliation(s)
- M. Deliu
- Division of Informatics, Imaging and Data SciencesFaculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - T. S. Yavuz
- Department of Pediatric AllergyGulhane School of MedicineAnkaraTurkey
- Department of Paediatric AllergyChildren's HospitalUniversity of BonnBonnGermany
| | - M. Sperrin
- Division of Informatics, Imaging and Data SciencesFaculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - D. Belgrave
- Department of MedicineSection of PaediatricsImperial College LondonLondonUK
| | - U. M. Sahiner
- Pediatric Allergy and Asthma UnitHacettepe University School of MedicineAnkaraTurkey
| | - C. Sackesen
- School of MedicinePediatric Allergy UnitKoc UniversityIstanbulTurkey
- Pediatric Allergy and Asthma UnitHacettepe University School of MedicineAnkaraTurkey
| | - O. Kalayci
- Pediatric Allergy and Asthma UnitHacettepe University School of MedicineAnkaraTurkey
| | - A. Custovic
- Department of MedicineSection of PaediatricsImperial College LondonLondonUK
| |
Collapse
|
40
|
Qi YY, Jiang GL, Wang LB, Wan CZ, Zhang XB, Qian LL. Lung Function in Wheezing Infants after Acute Lower Respiratory Tract Infection and Its Association with Respiratory Outcome. Chin Med J (Engl) 2017; 130:4-10. [PMID: 28051016 PMCID: PMC5221110 DOI: 10.4103/0366-6999.196577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Wheezing is common in early childhood and remains an important health concern. The aim of this study was to assess the lung function of wheezing infants and to investigate the relationship between lung function and respiratory outcome. Methods: Infants <2 years of age with acute lower respiratory tract infection (ALRTI) who had undergone lung function tests were included in the study. They were assigned to wheeze or no wheeze group based on physical examination. Infants without any respiratory diseases were enrolled as controls. Lung function was measured during the acute phase and 3 months after ALRTI. One-year follow-up for infants with ALRTI was achieved. Results: A total of 252 infants with ALRTI who had acceptable data regarding tidal breathing were included in the final analysis. Compared with the control and the no wheeze groups, infants in the wheeze group had significantly decreased time to peak tidal expiratory flow as a percentage of total expiratory time (TPTEF/TE) (20.1 ± 6.4% vs. 34.4 ± 6.2% and 26.4 ± 8.3%, respectively, P < 0.0001) and significantly increased peak tidal expiratory flow (PTEF) (90.7 ± 26.3 ml/s vs. 79.3 ± 18.4 ml/s and 86.1 ± 28.0 ml/s, respectively, P < 0.01), sReff and Reff. The infants in the wheeze group still had lower TPTEF/TE and volume to peak tidal expiratory flow as a percentage of total expiratory volume (VPTEF/VE) than the no wheeze infants 3 months after the ALRTI. Moreover, there was a significant inverse relationship between TPTEF/TE, VPTEF/VE, and the recurrence of wheezing and pneumonia. Conclusions: Impaired lung function was present in wheezing infants with ALRTI and the deficits persisted. In addition, the lower level of TPTEF/TE and VPTEF/VE was a risk factor for poor respiratory outcome.
Collapse
Affiliation(s)
- Yuan-Yuan Qi
- Department of Respiration, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Gao-Li Jiang
- Department of Respiration, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Li-Bo Wang
- Department of Respiration, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Cheng-Zhou Wan
- Department of Respiration, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Xiao-Bo Zhang
- Department of Respiration, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Li-Ling Qian
- Department of Respiration, Children's Hospital of Fudan University, Shanghai 201102, China
| |
Collapse
|
41
|
Lee E, Lee SH, Kwon JW, Kim YH, Yoon J, Cho HJ, Yang SI, Jung YH, Kim HY, Seo JH, Kim HB, Lee SY, Kwon HJ, Hong SJ. Persistent asthma phenotype related with late-onset, high atopy, and low socioeconomic status in school-aged Korean children. BMC Pulm Med 2017; 17:45. [PMID: 28231776 PMCID: PMC5324247 DOI: 10.1186/s12890-017-0387-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 02/16/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Treatment guidelines for asthma have been established based on asthma severity; there are limitations in the identification of underlying pathophysiology and prediction of prognosis in heterogeneous phenotypes of asthma. Although the complex interactions between environmental and genetic factors affect the development and progression of asthma, studies on asthma phenotypes considering environmental factors are limited. This study aimed to identify asthma phenotypes using latent class analysis including environmental factors in school-age children. METHODS We included 235 children (6-8 years) with parent-reported, physician-diagnosed asthma from the Children's HEalth and Environmental Research (CHEER) study, which is a 4-year prospective follow-up study with 2-year intervals. At every survey, pulmonary function tests, methacholine challenge tests and blood tests with questionnaire were conducted. RESULTS Four asthma phenotypes were identified. Cluster 1 (22% of children) was characterized by high prevalence of atopy and mild symptoms; subjects in cluster 2 (17%) consisted of less atopy and normal lung function, but intermittent troublesome; cluster 3 (29%) experienced late-onset atopic troublesome asthma with decreased lung function in combination with low socioeconomic status; and cluster 4 was associated with early-onset and less-atopic infrequent asthma. CONCLUSIONS Late-onset, high atopy, and low socioeconomic status are associated with troublesome persistent asthma phenotype in school-age children. Environmental factors might be implicated in the clinical heterogeneity of asthma. Asthma phenotypes considering diverse factors might be more helpful in the identification of asthma pathogenesis and its prevention.
Collapse
Affiliation(s)
- Eun Lee
- Department of Pediatrics, Chonnam National University Hospital, Gwangju, South Korea
| | - Si Hyeon Lee
- Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ji-Won Kwon
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Young-Ho Kim
- Department of Pediatrics, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Jisun Yoon
- Department of Pediatrics, Childhood Asthma and Atopy Center, Environmental Health Center, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, South Korea
| | - Hyun-Ju Cho
- Department of Pediatrics, Childhood Asthma and Atopy Center, Environmental Health Center, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, South Korea
| | - Song-I Yang
- Department of Pediatrics, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Young-Ho Jung
- Department of Pediatrics, CHA University School of Medicine, Seongnam, South Korea
| | - Hyung Young Kim
- Department of Pediatrics, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Ju-Hee Seo
- Department of Pediatrics, Dankook University College of Medicine, Cheonan, South Korea
| | - Hyo Bin Kim
- Department of Pediatrics, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, South Korea
| | - So Yeon Lee
- Department of Pediatrics, Childhood Asthma and Atopy Center, Environmental Health Center, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, South Korea
| | - Ho-Jang Kwon
- Department of Preventive Medicine, Dankook University College of Medicine, Cheonan, South Korea
| | - Soo-Jong Hong
- Department of Pediatrics, Childhood Asthma and Atopy Center, Environmental Health Center, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, South Korea.
| |
Collapse
|
42
|
Belgrave D, Henderson J, Simpson A, Buchan I, Bishop C, Custovic A. Disaggregating asthma: Big investigation versus big data. J Allergy Clin Immunol 2017; 139:400-407. [PMID: 27871876 PMCID: PMC5292995 DOI: 10.1016/j.jaci.2016.11.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/07/2016] [Accepted: 11/09/2016] [Indexed: 12/21/2022]
Abstract
We are facing a major challenge in bridging the gap between identifying subtypes of asthma to understand causal mechanisms and translating this knowledge into personalized prevention and management strategies. In recent years, "big data" has been sold as a panacea for generating hypotheses and driving new frontiers of health care; the idea that the data must and will speak for themselves is fast becoming a new dogma. One of the dangers of ready accessibility of health care data and computational tools for data analysis is that the process of data mining can become uncoupled from the scientific process of clinical interpretation, understanding the provenance of the data, and external validation. Although advances in computational methods can be valuable for using unexpected structure in data to generate hypotheses, there remains a need for testing hypotheses and interpreting results with scientific rigor. We argue for combining data- and hypothesis-driven methods in a careful synergy, and the importance of carefully characterized birth and patient cohorts with genetic, phenotypic, biological, and molecular data in this process cannot be overemphasized. The main challenge on the road ahead is to harness bigger health care data in ways that produce meaningful clinical interpretation and to translate this into better diagnoses and properly personalized prevention and treatment plans. There is a pressing need for cross-disciplinary research with an integrative approach to data science, whereby basic scientists, clinicians, data analysts, and epidemiologists work together to understand the heterogeneity of asthma.
Collapse
Affiliation(s)
| | - John Henderson
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Angela Simpson
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Iain Buchan
- Health Informatics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | | | - Adnan Custovic
- Department of Paediatrics, Imperial College, London, United Kingdom.
| |
Collapse
|
43
|
Del Giacco SR, Bakirtas A, Bel E, Custovic A, Diamant Z, Hamelmann E, Heffler E, Kalayci Ö, Saglani S, Sergejeva S, Seys S, Simpson A, Bjermer L. Allergy in severe asthma. Allergy 2017; 72:207-220. [PMID: 27775836 DOI: 10.1111/all.13072] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2016] [Indexed: 12/20/2022]
Abstract
It is well recognized that atopic sensitization is an important risk factor for asthma, both in adults and in children. However, the role of allergy in severe asthma is still under debate. The term 'Severe Asthma' encompasses a highly heterogeneous group of patients who require treatment on steps 4-5 of GINA guidelines to prevent their asthma from becoming 'uncontrolled', or whose disease remains 'uncontrolled' despite this therapy. Epidemiological studies on emergency room visits and hospital admissions for asthma suggest the important role of allergy in asthma exacerbations. In addition, allergic asthma in childhood is often associated with severe asthma in adulthood. A strong association exists between asthma exacerbations and respiratory viral infections, and interaction between viruses and allergy further increases the risk of asthma exacerbations. Furthermore, fungal allergy has been shown to play an important role in severe asthma. Other contributing factors include smoking, pollution and work-related exposures. The 'Allergy and Asthma Severity' EAACI Task Force examined the current evidence and produced this position document on the role of allergy in severe asthma.
Collapse
Affiliation(s)
- S. R. Del Giacco
- Department of Medical Sciences and Public Health; University of Cagliari; Cagliari Italy
| | - A. Bakirtas
- Department of Pediatric Allergy and Asthma; School of Medicine; Gazi University; Ankara Turkey
| | - E. Bel
- Department of Respiratory Medicine; Academic Medical Centre; University of Amsterdam; Amsterdam The Netherlands
| | - A. Custovic
- Department of Paediatrics; Imperial College London; London UK
| | - Z. Diamant
- Department of General Practice and Department of Clinical Pharmacy & Pharmacology; University Medical Centre Groningen; University of Groningen; Groningen The Netherlands
- Department of Respiratory Medicine and Allergology; Lund University; Lund Sweden
| | - E. Hamelmann
- Klinik für Kinder and Jugendmedizin Kinderzentrum; Bethel Evangelisches Krankenhaus; Allergy Center; Ruhr University Bochum; Bielefeld Germany
| | - E. Heffler
- Respiratory Medicine and Allergology - Department of Experimental and Clinical Medicine; University of Catania; Catania Italy
| | - Ö. Kalayci
- School of Medicine; Hacettepe University; Ankara Turkey
| | - S. Saglani
- National Heart & Lung Institute; Imperial College London; London UK
| | - S. Sergejeva
- Institute of Technology; University of Tartu; Tartu Estonia
| | - S. Seys
- Department of Microbiology and Immunology; Laboratory of Clinical Immunology; KU Leuven Belgium
| | - A. Simpson
- Centre Lead for Respiratory Medicine and Allergy; University Hospital of South Manchester; Education and Research Centre; University of Manchester; Manchester UK
| | - L. Bjermer
- Department of Respiratory Medicine and Allergology; Lund University; Lund Sweden
| |
Collapse
|
44
|
Carr TF, Bleecker E. Asthma heterogeneity and severity. World Allergy Organ J 2016; 9:41. [PMID: 27980705 PMCID: PMC5129643 DOI: 10.1186/s40413-016-0131-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 11/22/2016] [Indexed: 02/06/2023] Open
Abstract
Asthma is a common, chronic inflammatory airways disease characterized by a clinical syndrome of bronchial hyperresponsiveness, inflammation, and reversible airflow obstruction. Individuals with asthma can vary widely in clinical presentation, severity, and pathobiology. The incident factors, pathogenesis, prognosis, and treatment of asthma remain incompletely understood. Utilizing measurable characteristics of asthmatic patients, including demographic, physiologic, and biologic markers, can however identify meaningful phenotypic categories in asthma. Identification of these phenotypes may help improve precision therapeutics targeted toward an individual’s’ disease, and may identify strategies for preventing progression of disease severity.
Collapse
Affiliation(s)
- Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724-5030 USA
| | - Eugene Bleecker
- Center for Genomics and Personalized Medicine Research, Wake Forest School of Medicine, Winston-Salem, NC USA
| |
Collapse
|
45
|
Deliu M, Belgrave D, Sperrin M, Buchan I, Custovic A. Asthma phenotypes in childhood. Expert Rev Clin Immunol 2016; 13:705-713. [PMID: 27817211 DOI: 10.1080/1744666x.2017.1257940] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Asthma is no longer thought of as a single disease, but rather a collection of varying symptoms expressing different disease patterns. One of the ongoing challenges is understanding the underlying pathophysiological mechanisms that may be responsible for the varying responses to treatment. Areas Covered: This review provides an overview of our current understanding of the asthma phenotype concept in childhood and describes key findings from both conventional and data-driven methods. Expert Commentary: With the vast amounts of data generated from cohorts, there is hope that we can elucidate distinct pathophysiological mechanisms, or endotypes. In return, this would lead to better patient stratification and disease management, thereby providing true personalised medicine.
Collapse
Affiliation(s)
- Matea Deliu
- a Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
| | - Danielle Belgrave
- b Department of Paediatrics , Imperial College of Science, Technology & Medicine , London , UK
| | - Matthew Sperrin
- a Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
| | - Iain Buchan
- a Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
| | - Adnan Custovic
- b Department of Paediatrics , Imperial College of Science, Technology & Medicine , London , UK
| |
Collapse
|
46
|
Wu J, Prosperi MCF, Simpson A, Hollams EM, Sly PD, Custovic A, Holt PG. Relationship between cytokine expression patterns and clinical outcomes: two population-based birth cohorts. Clin Exp Allergy 2016; 45:1801-11. [PMID: 26061524 PMCID: PMC4950290 DOI: 10.1111/cea.12579] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 03/17/2015] [Accepted: 04/25/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND Models that incorporate patterns of multiple cytokine responses to allergens, rather than individual cytokine production, may better predict sensitization and asthma. OBJECTIVE To characterize the patterns of peripheral blood mononuclear cells' (PBMCs) cytokine responses to house dust mite (HDM) allergens among children from two population-based birth cohorts using machine learning techniques. METHODS PBMCs collected at 8 years of age from the UK Manchester Asthma and Allergy Study (n = 268) and at 14 years of age from the Australian Raine Study (n = 1374) were cultured with HDM extract (10 μg/ml). Cytokine expression (IL-13, IL-5, IFN-γ, and IL10) was measured in the supernatant. Cytokine patterns were identified using a Gaussian mixture model clustering, and classification stability was assessed by bootstrapping. RESULTS A six-class model indicated complex latent structure of cytokine expression. Based on the characteristics of each class, we designated them as follows: 'Nonresponders' (n = 905, 55%); 'IL-10 responders' (n = 49, 3%); 'IFN-γ and IL-13 medium responders' (n = 56, 3.4%); 'IL-13 medium responders' (n = 351, 21.4%); 'IL-5 and IL-13 medium responders' (n = 77, 4.7%); and 'IL-13 and IL-5 high responders' (n = 204, 12.4%). 'IL-13 and IL-5 high responders' were at much higher risk of HDM sensitization and asthma compared to all other classes, with 88% of children assigned to this class being sensitized and 28.5% having asthma. CONCLUSION Using model-based clustering, we identified several distinct patterns of cytokine response to HDM and observed interplay between cytokine expression level, cytokine patterns (especially IL-13 and IL-5), and clinical outcomes. 'IL-13 and IL-5 high responders' class was strongly associated with HDM sensitization. However, among HDM-sensitized children, one-third showed no PBMC response to HDM, and the majority of HDM-sensitized children did not have asthma or wheeze. Our findings suggest that positive HDM 'allergy tests' and asthma are associated with a broad range of immunophenotypes, which may have important implications for the use of cytokine-targeted treatment approaches.
Collapse
Affiliation(s)
- J Wu
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, University of Manchester, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - M C F Prosperi
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, University of Manchester, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK.,Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK
| | - A Simpson
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, University of Manchester, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - E M Hollams
- Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, WA, Australia
| | - P D Sly
- Queensland Children's Medical Research Institute, the University of Queensland, Brisbane, Qld, Australia
| | - A Custovic
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, University of Manchester, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - P G Holt
- Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, WA, Australia.,Queensland Children's Medical Research Institute, the University of Queensland, Brisbane, Qld, Australia
| |
Collapse
|
47
|
Spycher BD, Kuehni CE. Asthma phenotypes in childhood: conceptual thoughts on stability and transition. Eur Respir J 2016; 47:362-5. [PMID: 26828043 DOI: 10.1183/13993003.02011-2015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Ben Daniel Spycher
- Paediatric Epidemiology, Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Claudia Elisabeth Kuehni
- Paediatric Epidemiology, Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| |
Collapse
|
48
|
Deliu M, Sperrin M, Belgrave D, Custovic A. Identification of Asthma Subtypes Using Clustering Methodologies. Pulm Ther 2016; 2:19-41. [PMID: 27512723 PMCID: PMC4959136 DOI: 10.1007/s41030-016-0017-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Indexed: 02/07/2023] Open
Abstract
Asthma is a heterogeneous disease comprising a number of subtypes which may be caused by different pathophysiologic mechanisms (sometimes referred to as endotypes) but may share similar observed characteristics (phenotypes). The use of unsupervised clustering in adult and paediatric populations has identified subtypes of asthma based on observable characteristics such as symptoms, lung function, atopy, eosinophilia, obesity, and age of onset. Here we describe different clustering methods and demonstrate their contributions to our understanding of the spectrum of asthma syndrome. Precise identification of asthma subtypes and their pathophysiological mechanisms may lead to stratification of patients, thus enabling more precise therapeutic and prevention approaches.
Collapse
Affiliation(s)
- Matea Deliu
- />Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Matthew Sperrin
- />Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK
| | | | - Adnan Custovic
- />Department of Paediatrics, Imperial College London, London, UK
| |
Collapse
|
49
|
Sears MR. Predicting asthma outcomes. J Allergy Clin Immunol 2016; 136:829-36; quiz 837. [PMID: 26449797 DOI: 10.1016/j.jaci.2015.04.048] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 04/14/2015] [Accepted: 04/17/2015] [Indexed: 12/31/2022]
Abstract
This review addresses predictors of remission or persistence of wheezing and asthma from early childhood through adulthood. Early childhood wheezing is common, but predicting who will remit or have persistent childhood asthma remains difficult. By adding parental history of asthma and selected infant biomarkers to the history of recurrent wheezing, the Asthma Predictive Index and its subsequent modifications provide better predictions of persistence than simply the observation of recurrent wheeze. Sensitization, especially to multiple allergens, increases the likelihood of development of classic childhood asthma. Remission is more likely in male subjects and those with milder disease (less frequent and less severe symptoms), less atopic sensitization, a lesser degree of airway hyperresponsiveness, and no concomitant allergic disease. Conversely, persistence is linked strongly to allergic sensitization, greater frequency and severity of symptoms, abnormal lung function, and a greater degree of airway hyperresponsiveness. A genetic risk score might predict persistence more accurately than family history. Remission of established adult asthma is substantially less common than remission during childhood and adolescence. Loss of lung function can begin early in life and tracks through childhood and adolescence. Despite therapy which controls symptoms and exacerbations, the outcomes of asthma appear largely resistant to pharmacologic therapy.
Collapse
Affiliation(s)
- Malcolm R Sears
- Department of Medicine, Faculty of Health Sciences, de Groote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
50
|
Holt PG, Strickland D, Bosco A, Belgrave D, Hales B, Simpson A, Hollams E, Holt B, Kusel M, Ahlstedt S, Sly PD, Custovic A. Distinguishing benign from pathologic TH2 immunity in atopic children. J Allergy Clin Immunol 2015; 137:379-87. [PMID: 26518094 DOI: 10.1016/j.jaci.2015.08.044] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 08/12/2015] [Accepted: 08/14/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although most children with asthma and rhinitis are sensitized to aeroallergens, only a minority of sensitized children are symptomatic, implying the underlying operation of efficient anti-inflammatory control mechanisms. OBJECTIVE We sought to identify endogenous control mechanisms that attenuate expression of IgE-associated responsiveness to aeroallergens in sensitized children. METHODS In 3 independent population samples we analyzed relationships between aeroallergen-specific IgE and corresponding allergen-specific IgG (sIgG) and associated immunophenotypes in atopic children and susceptibility to asthma and rhinitis, focusing on responses to house dust mite and grass. RESULTS Among mite-sensitized children across all populations and at different ages, house dust mite-specific IgG/IgE ratios (but not IgG4/IgE ratios) were significantly lower in children with asthma compared with ratios in those without asthma and lowest among the most severely symptomatic. This finding was mirrored by relationships between rhinitis and antibody responses to grass. Depending on age/allergen specificity, 20% to 40% of children with allergen-specific IgE (sIgE) of 0.35 kU/L or greater had negative skin test responses, and these children also expressed the high sIgG/sIgE immunophenotype. sIgG1 from these children inhibited allergen-induced IgE-dependent basophil activation in a dose-dependent fashion. Profiling of aeroallergen-specific CD4(+) TH memory responses revealed positive associations between sIgG/sIgE ratios and IL-10-dependent gene signatures and significantly higher IL-10/TH2 cytokine (protein) ratios among nonsymptomatic children. CONCLUSION In addition to its role in blocking TH2 effector activation in the late-phase allergic response, IL-10 is a known IgG1 switch factor. We posit that its production during allergen-induced memory responses contributes significantly to attenuation of inflammation through promoting IgG1-mediated damping of the FcεRI-dependent acute-phase reaction. sIgG1/sIgE balance might represent a readily accessible therapeutic target for asthma/rhinitis control.
Collapse
Affiliation(s)
- Patrick G Holt
- Telethon Kids Institute, University of Western Australia, Perth, Australia; Queensland Children's Medical Research Institute, University of Queensland, Brisbane, Australia.
| | - Deborah Strickland
- Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Anthony Bosco
- Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Danielle Belgrave
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, University of Manchester and University Hospital of South Manchester, Manchester, United Kingdom
| | - Belinda Hales
- Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Angela Simpson
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, University of Manchester and University Hospital of South Manchester, Manchester, United Kingdom
| | - Elysia Hollams
- Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Barbara Holt
- Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Merci Kusel
- Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Staffan Ahlstedt
- Centre for Allergy Research, Karolinska Institute, Stockholm, Sweden
| | - Peter D Sly
- Queensland Children's Medical Research Institute, University of Queensland, Brisbane, Australia
| | - Adnan Custovic
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, University of Manchester and University Hospital of South Manchester, Manchester, United Kingdom
| |
Collapse
|