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Akenroye A, Marshall J, Simon AL, Hague C, Costa R, Jamal-Allial A, McMahill-Walraven CN, Haffenreffer K, Han A, Wu AC. Smaller Differences in the Comparative Effectiveness of Biologics in Reducing Asthma-Related Hospitalizations Compared With Overall Exacerbations. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00211-3. [PMID: 38431251 DOI: 10.1016/j.jaip.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Evidence on the comparative effectiveness of respiratory biologics remains sparse. OBJECTIVE We sought to evaluate the comparative effectiveness of omalizumab, mepolizumab, benralizumab, and dupilumab in a matched retrospective cohort of patients with asthma. METHODS We identified patients with asthma aged ≥18 years who were incident users of these biologics between November 1, 2018, and June 30, 2023, in administrative claims data from the Food and Drug Administration's Sentinel System and Merative MarketScan Commercial Database. We compared asthma-related exacerbations and hospitalizations in the 12 months since biologic prescription in pairwise comparisons of propensity score-matched cohorts. Covariates used in matching included age, sex, allergic comorbidities, baseline asthma medications use, and the Charlson Comorbidity Index. Incidence rate ratios (IRR) and 95% confidence intervals (CI) were estimated using negative binomial regression models. RESULTS A total of 893 patients on mepolizumab, 1300 on benralizumab, 1170 on omalizumab, and 1863 on dupilumab were identified. The average age was 55 years, and two-thirds of the participants were female. At baseline, over 80% of these individuals had an active prescription for an inhaled corticosteroid. Almost half of patients on dupilumab had concomitant nasal polyposis compared with 6% to 13% of patients on the other biologics. Covariates were balanced after matching. In matched analyses, dupilumab was associated with the lowest incidence of exacerbations over the follow-up period (vs dupilumab): mepolizumab (IRR: 1.36; 95% CI: 1.12, 1.64), omalizumab (IRR: 1.33; 95% CI: 1.13, 1.58), benralizumab (IRR: 1.19; 95% CI: 1.00, 1.41). For exacerbations leading to hospitalizations, benralizumab and mepolizumab were associated with the lowest incidence of hospitalizations, and the greatest difference was between mepolizumab versus dupilumab (IRR: 0.76; 95% CI: 0.56, 1.03). CONCLUSIONS Dupilumab was associated with the lowest incidence of overall exacerbations, and mepolizumab with the lowest incidence of asthma hospitalizations in this administrative claims-based cohort of individuals with asthma. Despite matching propensity scores, residual confounding, such as baseline eosinophil count, may explain some of these findings.
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Affiliation(s)
- Ayobami Akenroye
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass; Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
| | - James Marshall
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Andrew L Simon
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Christian Hague
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Rebecca Costa
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | | | | | - Katie Haffenreffer
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Amy Han
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Ann Chen Wu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
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2
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Anderson WC, Banzon TM, Chawes B, Papadopoulos NG, Phipatanakul W, Szefler SJ. Factors to Consider in Prescribing Asthma Biologic Therapies to Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:693-701. [PMID: 36646381 DOI: 10.1016/j.jaip.2022.12.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 01/15/2023]
Abstract
The increasing availability of biologics, both by expanding age indications and by development of new therapies, provides additional options to treat children and adolescents with severe asthma. However, the evidence for these biologics in these populations is limited compared with that for adult studies. As such, before initiation of therapy, possible alternative therapies that can also provide asthma control, confirmation of the diagnosis of asthma, management of comorbidities, and assessment of adherence should be explored. The choice of a biologic should be a shared decision-making process between providers and families, balancing biologic efficacy, goals of care, administration, and ability to treat multiple conditions. Response to treatment should be periodically evaluated not only to ensure an ineffective treatment is not continued but also to consider when to potentially discontinue therapy should it be beneficial. The utilization of biologics in children and adolescents with severe asthma also leads to unanswered questions on their role in disease remission and long-term outcomes.
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Affiliation(s)
- William C Anderson
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
| | - Tina M Banzon
- Division of Allergy and Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Bo Chawes
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Wanda Phipatanakul
- Division of Asthma, Allergy, Dermatology, Rheumatology, Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Stanley J Szefler
- Section of Pediatric Pulmonary and Sleep Medicine, Breathing Institute, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
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3
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Nassar RI, Saini B, Obeidat NM, Atatreh N, Basheti I. Assessing adherence to medications: Is there a difference between a subjective method and an objective method, or between using them concurrently? Pharm Pract (Granada) 2022; 20:2723. [PMID: 36793904 PMCID: PMC9891798 DOI: 10.18549/pharmpract.2022.4.2723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 09/05/2022] [Indexed: 12/13/2022] Open
Abstract
Background Patients' adherence to medication can be assessed by several subjective or objective methods. The Global Initiative for Asthma (GINA) has recommended the use of both measures simultaneously. Objective To assess patients' adherence to medication using a subjective or an objective method separately, and via using a combination of both methods. As well as identifying the degree of agreement between the two methods. Methods Participants who met the study inclusion criteria completed the Adherence to Asthma Medication Questionnaire (AAMQ). A retrospective audit was conducted in order to extract pharmacy refill records for the previous twelve months. The patients' pharmacy refill records were expressed using the Medication Possession Ratio (MPR). Data were analyzed using the Statistical Package for Social Science. The degree of agreement was determined by Cohen's kappa coefficient (κ). Results In terms of the difference in the ability of each method to identify non-adherent patients, a higher percentage of non-adherent patients were identified using the self-reported AAMQ (61.4%) compared to the pharmacy refill records (34.3%). When both methods, in combination, were used to assess adherence, the percentage of non-adherent patients was 80.0%, which is higher than each method when used separately. Twenty percent of the patients were considered adherent on both assessment methods, while 15.7% were considered non-adherent via both methods. Consequently, the AAMQ and pharmacy refill records agreed on 35.7% of the patients. The degree of agreement analysis showed a low correlation between the two methods. Conclusion The combination strategy resulted in a higher percentage of non-adherent patients, compared to using a subjective (the AAMQ) or an objective (the pharmacy refill records) method. The GINA guideline proposition may be supported by the present study's findings.
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Affiliation(s)
- Razan I Nassar
- MSc. Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan.
| | - Bandana Saini
- PhD. Professor in Clinical Pharmacy, College of Pharmacy, University of Sydney, Sydney, Australia.
| | - Nathir M Obeidat
- PhD. Professor in Medicine, Faculty of Medicine, The University of Jordan, Amman, Jordan, Department of Internal Medicine, Respiratory and Sleep Medicine, Jordan University Hospital.
| | - Noor Atatreh
- PhD. College of Pharmacy, Al Ain University, Abu Dhabi, United Arab Emirates, AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, United Arab Emirates.
| | - Iman Basheti
- PhD. Faculty of Pharmacy, Applied Science Private University, 11931, Amman, Jordan; Faculty of Pharmacy, The University of Sydney, 2006, Sydney, Australia.
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4
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Aierken A, Yu Su Fu BWMEM, Xu P. Tiotropium as an add‑on treatment to inhaled corticosteroids in children with severe and mild symptomatic asthma: Multi‑center observational study for efficacy and safety analysis. Exp Ther Med 2022; 24:577. [DOI: 10.3892/etm.2022.11514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/15/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Aibibai Aierken
- Department of Pediatrics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region 830054, P.R. China
| | - Bu Wei Mai Erye Mu Yu Su Fu
- Department of Pediatrics, The First People's Hospital of Kashi, Kashi, Xinjiang Uygur Autonomous Region 844000, P.R. China
| | - Peiru Xu
- Department of Pediatrics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region 830054, P.R. China
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5
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Clinical form of asthma and vaccine immunity in preschoolers. Postepy Dermatol Alergol 2021; 38:123-130. [PMID: 34408578 PMCID: PMC8362791 DOI: 10.5114/ada.2021.104287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 08/09/2019] [Indexed: 01/20/2023] Open
Abstract
Introduction Asthma is the most common chronic disease in children. Its exacerbation results from allergic and infectious diseases. Aim To assess the influence of a clinical form of asthma on preschoolers’ vaccine immunity following 3 years after the completion of the mandatory vaccination programme. Material and methods The study encompassed 172 preschool children with asthma being newly diagnosed, including 140 patients with mild asthma and 32 with moderate asthma, whose vaccine immunity (level of IgG-specific antibodies) was assessed after the mandatory early vaccines had been administered in the early childhood. Monovalent vaccines (HBV + IPV + Hib) along with a three-component combined vaccine (DTwP) and MMR were given to 86 children while a six-component combined vaccine (DTaP + IPV + Hib + HBV) along with a three-component MMR vaccine were administered to the remaining 86 children. The immunity class for particular vaccinations was assessed according to the manufacturers’ instructions. Results Children suffering from mild asthma had considerably more frequently vaccinations administered on time (p < 0.001) and the type of vaccines (monovalent or highly-combined) administered did not have a significant influence on the clinical form of asthma in the children examined (p = 0.6951). Apart from the vaccines against hepatitis B and rubella where considerably more frequently a high level of antibodies occurred in children with mild asthma, the antibody levels to other vaccines, namely diphtheria, tetanus, pertussis, Hib and mumps, were not associated with the severity of asthma. Conclusions Moderate asthma may have a negative impact on remote vaccine immunity to HBV and rubella.
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6
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Sweenie R, Cushing CC, Fleming KK, Prabhakaran S, Fedele DA. Daily adherence variability and psychosocial differences in adolescents with asthma: a pilot study. J Behav Med 2021; 45:148-158. [PMID: 34357514 DOI: 10.1007/s10865-021-00247-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 07/20/2021] [Indexed: 11/24/2022]
Abstract
Adolescents with asthma endorse psychosocial difficulties as barriers to inhaled corticosteroid adherence. This study examined patterns of variability in adherence and within-person associations of psychosocial variables with adherence across days. Participants included twenty-five adolescents (Mage = 14.7, SD = 1.68; 48% male) with persistent asthma. We measured adherence via electronic monitoring. Adolescents completed daily surveys measuring asthma symptoms, stress, mood, and affect. We examined within-person differences in the effect of symptoms and psychosocial variables on adherence. Adherence decreased over time. The addition of a random slope improved model fit (- 2ΔLL(1) = 9.36, p < .01). Greater asthma symptoms were significantly associated with higher adherence at the within-person level and with lower adherence between persons. We observed evidence of individual differences in the associations of stress and affect with adherence. Within-person, day-level fluctuations in adherence occur. Symptoms and psychosocial variables may influence adherence. Individually tailored interventions may effectively address nonadherence.
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Affiliation(s)
- Rachel Sweenie
- Department of Clinical and Health Psychology, University of Florida, P.O. Box 100165, Gainesville, FL, 32610-0165, USA.
| | - Christopher C Cushing
- Dole Human Development Center, University of Kansas, Schiefelbusch Institute for Life Span Studies, 1000 Sunnyside Ave., Lawrence, KS, 66045, USA.,Clinical Child Psychology Program, University of Kansas, Dole Human Development Center, 1000 Sunnyside Ave., Lawrence, KS, 66045, USA
| | - Kandace K Fleming
- Dole Human Development Center, University of Kansas, Schiefelbusch Institute for Life Span Studies, 1000 Sunnyside Ave., Lawrence, KS, 66045, USA
| | - Sreekala Prabhakaran
- Department of Pediatrics, University of Florida, 1600 SW Archer Road, Gainesville, FL, 32610, USA
| | - David A Fedele
- Department of Clinical and Health Psychology, University of Florida, P.O. Box 100165, Gainesville, FL, 32610-0165, USA
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Ramachandran HJ, Jiang Y, Shan CH, Tam WWS, Wang W. A systematic review and meta-analysis on the effectiveness of swimming on lung function and asthma control in children with asthma. Int J Nurs Stud 2021; 120:103953. [PMID: 34051586 DOI: 10.1016/j.ijnurstu.2021.103953] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/02/2021] [Accepted: 04/14/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Swimming has been considered the most appropriate activity for children with asthma for its lower asthmogenicity compared to land-based activities. However, the benefits of swimming have been hampered by reports of increased asthma risks, airway inflammation and bronchial hyper-responsiveness from exposure to chlorine by-products in swimming pools. Thus, the role of swimming for children with asthma remains unclear. OBJECTIVES To determine the effectiveness of swimming as an intervention on lung function and asthma control in children below the age of 18 years. Any adverse effects from swimming on asthma were also examined. METHODS Searches were performed across six databases systematically (PubMed, CINAHL, Embase, CENTRAL, Scopus, and PsycINFO). Randomized controlled trials (RCTs), quasi-experimental studies and interventional studies with at least one control/comparator group that were published in English were included. All eligible studies were screened with risk of bias examined by two independent reviewers. Meta-analyses were conducted using Review Manager 5.4 software while narrative syntheses were performed where meta-analysis was inappropriate and heterogeneity was present. RESULTS 1710 records were retrieved from the search. A total of 9 studies with 387 participants were included in this review after screening. Swimming was found to have favourable effects on forced expiratory volume in one second (L) and forced vital capacity (%), but not for forced expiratory volume in one second (%) and peak expiratory flow (%). Narrative synthesis on asthma control and adverse effects were in favour of the swimming group. CONCLUSION Future studies that are adequately powered, involve swimming interventions of sufficient intensity, frequency and duration, examine cumulative exposures to chlorine by-products and take into account potential cofounders are warranted.
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Affiliation(s)
- Hadassah Joann Ramachandran
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD 11,10 Medical Drive, Singapore 117597, Singapore.
| | - Ying Jiang
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD 11,10 Medical Drive, Singapore 117597, Singapore.
| | - Coral Hui Shan
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD 11,10 Medical Drive, Singapore 117597, Singapore.
| | - Wilson Wai San Tam
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD 11,10 Medical Drive, Singapore 117597, Singapore.
| | - Wenru Wang
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD 11,10 Medical Drive, Singapore 117597, Singapore.
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8
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Zhao D, Chen D, Li L, Zou Y, Shang Y, Zhang C, Zhang L, Pan J, Chen Q, Ai T, Ni Q. CARE: an observational study of adherence to home nebulizer therapy among children with asthma. Ther Adv Respir Dis 2021; 15:1753466620986391. [PMID: 33541235 PMCID: PMC7874342 DOI: 10.1177/1753466620986391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: The prevalence of pediatric asthma in China is approximately 3%, and asthma remains poorly controlled in many of these patients. This study assessed the rate of adherence to home nebulizer treatment in paediatric patients in China. Methods: The CARE study was a 12-week, multicentre, prospective, observational study across 12 tertiary hospitals in China. Patients were aged 0–14 years, clinically diagnosed with asthma and prescribed home nebulizer inhaled corticosteroid (ICS) therapy for ⩾3 months. The primary endpoint was electronically monitored treatment adherence. Patients attended onsite visits at 0, 4, 8 and 12 weeks to assess asthma control, severity and treatment adherence (recorded by electronic monitoring devices and caregivers). Results: The full analysis set included 510 patients. Median treatment adherence reported by electronic monitoring devices was 69.9%, and median caregiver-reported adherence was 77.9%. The proportion of patients with well-controlled asthma increased from 12.0% at baseline to 77.5% at visit 4. Increased time between asthma diagnosis and study enrolment was a significant predictor for better adherence [coefficient: 0.01, p = 0.0138; 95% confidence interval (CI): 0.00, 0.01] and asthma control (odds ratio = 1.001, p = 0.0498; 95% CI: 1.000, 1.002). Negative attitude to treatment by the caregiver was associated with poorer asthma control. Conclusions: Adherence to home nebulization, a widely used treatment for asthma, was high among Chinese pediatric patients. Asthma control improved with increasing treatment duration. These results suggest that home nebulization of ICS is an effective and recommendable long-term treatment for paediatric patients with asthma. Trial registration ClinicalTrials.gov identifier: NCT03156998 The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Deyu Zhao
- Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing 210008, China
| | - Dehui Chen
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Ling Li
- Wuxi Children's Hospital, Wuxi, China
| | - YingXue Zou
- Tianjin Children's Hospital, Tianjing, China
| | - Yunxiao Shang
- ShengJing Hospital of China Medical University, Shenyang, China
| | | | - Li Zhang
- Nanjing First Hospital, Nanjing, China
| | | | - Qiang Chen
- Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Tao Ai
- Chengdu Women & Children's Central Hospital, Chengdu, China
| | - Qian Ni
- Second Hospital of Lanzhou University, Lanzhou, China
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9
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Abstract
PURPOSE OF REVIEW This review aims to recognize the multifactorial cause of asthma, from the influence of mother until adulthood, highlight the main characteristics of the disease at different ages and summarize the evidence of potential prevention strategies. RECENT FINDINGS To date, regarding the prenatal period, the presence of specific genes, maternal asthma, drugs, and tobacco exposure are the most relevant predisposing features for an asthmatic offspring. For newborns, preterm, bronchopulmonary dysplasia, and low birth weight has been associated with low lung function. Among young children, atopic dermatitis, lower respiratory tract infections, and increased levels of total Immunoglobulin E (IgE) and allergen-specific IgE are important determinants.Breastfeeding has been demonstrated being protective for the onset of asthma. Allergen immunotherapy has also been shown to have significant preventive effect decreasing asthma development. Inhaled corticosteroids use in early childhood prevents exacerbations but does not alter the natural history of asthma. Other interventions, such as the use of palivizumab, probiotics, vitamin D supplementation, and fish consumption presented controversial results. SUMMARY A good knowledge of risk factors for asthma development, from prenatal period to adulthood, may lead to efficacious preventive strategies. Further data of long-term follow-up in population-based studies according to different phenotypes are needed.
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de Lacerda LB, Rios WM, Masson AP, Brandão IT, Milani TM, Borges MC, Ramalho LNZ, Barbosa MCR, Miyoshi A, Silva CL. Oral administration of Hsp65-producing Lactococcus lactis attenuates allergic asthma in a murine model. J Appl Microbiol 2020; 130:2075-2086. [PMID: 33124086 DOI: 10.1111/jam.14913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/09/2020] [Accepted: 10/23/2020] [Indexed: 01/09/2023]
Abstract
AIMS Allergic asthma is a chronic inflammatory lung disease characterized by a Th2-type immune response pattern. The development of nonspecific immunotherapy is one of the primary goals for the control of this disease. METHODS AND RESULTS In this study, we evaluated the therapeutic effects of Lactococcus lactis-producing mycobacterial heat shock protein 65 (LLHsp65) in an ovalbumin (OVA)-induced allergic asthma model. OVA-challenged BALB/c mice were orally administrated with LLHsp65 for 10 consecutive days. The results demonstrate that LLhsp65 attenuates critical features of allergic inflammation, like airway hyperresponsiveness and mucus production. Likewise, the treatment decreases the pulmonary eosinophilia and the serum level of OVA-specific IgE. In addition to deviating immune responses towards Th1-cytokine profile, increase regulatory T cells, and cytokine levels, such as IL-6 and IL-10. CONCLUSIONS Our results reveal that the mucosal immunotherapy of LLHsp65 significantly reduces the overall burden of airway allergic inflammation, suggesting a promising therapeutic strategy for allergic asthma treatment. SIGNIFICANCE AND IMPACT OF THE STUDY This research reveals new perspectives on nonspecific immunotherapy based on the delivery of recombinant proteins by lactic acid bacteria to treat of allergic disorders.
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Affiliation(s)
- L B de Lacerda
- Department of Biochemistry and Immunology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - W M Rios
- Department of Biochemistry and Immunology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - A P Masson
- Department of Biochemistry and Immunology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - I T Brandão
- Department of Biochemistry and Immunology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - T M Milani
- Department of Internal Medicine, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - M C Borges
- Department of Internal Medicine, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - L N Z Ramalho
- Department of Pathology Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - M C R Barbosa
- Department of Biochemistry and Immunology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - A Miyoshi
- Department of Ecology, Genetics and Evolution, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - C L Silva
- Department of Biochemistry and Immunology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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Szefler SJ, Fitzgerald DA, Adachi Y, Doull IJ, Fischer GB, Fletcher M, Hong J, García-Marcos L, Pedersen S, Østrem A, Sly PD, Williams S, Winders T, Zar HJ, Bush A, Lenney W. A worldwide charter for all children with asthma. Pediatr Pulmonol 2020; 55:1282-1292. [PMID: 32142219 PMCID: PMC7187318 DOI: 10.1002/ppul.24713] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/14/2020] [Indexed: 12/21/2022]
Abstract
Childhood asthma is a huge global health burden. The spectrum of disease, diagnosis, and management vary depending on where children live in the world and how their community can care for them. Global improvement in diagnosis and management has been unsatisfactory, despite ever more evidence-based guidelines. Guidelines alone are insufficient and need supplementing by government support, changes in policy, access to diagnosis and effective therapy for all children, with research to improve implementation. We propose a worldwide charter for all children with asthma, a roadmap to better education and training which can be adapted for local use. It includes access to effective basic asthma medications. It is not about new expensive medications and biologics as much can be achieved without these. If implemented carefully, the overall cost of care is likely to fall and the global future health and life chance of children with asthma will greatly improve. The key to success will be community involvement together with the local and national development of asthma champions. We call on governments, institutions, and healthcare services to support its implementation.
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Affiliation(s)
- Stanley J Szefler
- Department of Pediatrics, Section of Pediatric Pulmonary and Sleep Medicine, Pediatric Asthma Research Program, Anschutz Medical Campus, Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Dominic A Fitzgerald
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Yuichi Adachi
- Department of Pediatrics, University of Toyama, Toyama, Japan
| | - Iolo J Doull
- Department of Paediatric Respiratory Medicine, Children's Hospital for Wales, Cardiff, UK
| | - Gilberto B Fischer
- Department of Paediatrics, Universidade Federal de Ciencias da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Monica Fletcher
- Asthma UK Centre for Applied Research, University of Edinburgh, Edinburgh, UK
| | - Jianguo Hong
- Department of Paediatrics, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Luis García-Marcos
- Department of Paediatrics, "Virgen de la Arrixaca" University Children's Hospital, University of Murcia, Murcia, Spain
| | - Søren Pedersen
- Paediatric Research Unit, Kolding Hospital, University of Southern Denmark, Kolding, Denmark
| | | | - Peter D Sly
- Children's Health and Environment Program and World Health Organisation Collaborating Centre for Children's Health and Environment, Child Health Research Centre, University of Queensland, Brisbane, Australia
| | - Siân Williams
- International Primary Care Respiratory Group, London, UK
| | - Tonya Winders
- Allergy & Asthma Network, Vienna, Virginia.,Global Allergy & Asthma Patient Platform, Vienna, Virginia
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Andy Bush
- Department of Paediatrics, National Heart and Lung Institute and Royal Brompton & Harefield NHS Foundation Trust, Imperial College, London, UK
| | - Warren Lenney
- Department of Child Health, Institute of Applied Clinical Science, Keele University, Keele, UK
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12
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Santino TA, Monteiro KS, de Paiva Azevedo M, Patino CM, Ahmed S, de Mendonça KM. Patient- and proxy-reported outcome measures instruments for the assessment of asthma control among adult and pediatric population: A protocol for systematic review. Medicine (Baltimore) 2020; 99:e20078. [PMID: 32384477 PMCID: PMC7220545 DOI: 10.1097/md.0000000000020078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Asthma is a chronic airways inflammatory disease considered as a serious public health problem. Since asthma is a lifelong condition, the assessment of its control is important to achieve a better self-management. Based on the advances of the assessment tools, many instruments have been developed to assess asthma control. Therefore, this systematic review aims to assess the measurement properties, the methodological quality, and the content of outcome measures of the available patient- and proxy-reported asthma control instruments. METHODS This is a systematic review protocol of the measurement properties of asthma control patient- and proxy-reported outcome instruments. Database searches will be primarily performed on MEDLINE, EMBASE, Web of Science, ScienceDirect and PsycINFO. A manual search of websites considered databases for questionnaires and reference lists will also be conducted. The methodological quality of the studies and the measurement properties will be critically appraised using the COSMIN risk of bias (RoB) checklist. The content of all measurement instruments will be compared based on the International Classification of Functioning, Disability and Health framework. RESULTS The findings from this systematic review will be disseminated through publication in a peer-reviewed journal and presented at scientific conferences. CONCLUSION The proposed systematic review will produce a comprehensive evaluation of the measurement properties of the currently available asthma control instruments for both adult and pediatric populations. We aim to help researchers and practitioners in their choice of an adequate instrument and to highlight the gaps in currently available tools. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number: CRD42019126042.
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Affiliation(s)
- Thayla A. Santino
- Graduate Program of Physical Therapy, Federal University of Rio Grande do Norte, Natal
| | | | | | - Cecília M. Patino
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sara Ahmed
- Faculty of Medicine, School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
| | - Karla M.P.P. de Mendonça
- Graduate Program of Physical Therapy, Federal University of Rio Grande do Norte, Natal
- Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil
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13
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De Keyser HH, Ramsey R, Federico MJ. They just don't take their medicines: Reframing medication adherence in asthma from frustration to opportunity. Pediatr Pulmonol 2020; 55:818-825. [PMID: 31944593 PMCID: PMC10187561 DOI: 10.1002/ppul.24643] [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: 08/01/2019] [Accepted: 01/03/2020] [Indexed: 12/19/2022]
Abstract
Assessing and addressing suboptimal adherence to asthma medications is a key component in the treatment of all children with asthma, particularly those with difficult-to-treat asthma. However, parents often overreport adherence to asthma medications. Increased medication adherence could lead to improved outcomes in the form of better asthma control and decreased asthma exacerbations, as well as decreased healthcare utilization costs. Yet there are many complex factors that affect medication adherence, and barriers are often different in each family. Social determinants of health, complex healthcare relationships, and patient-related factors may all affect medication adherence. Multicomponent patient-centered strategies, as well as strategies that utilize technology and habit formation strategies may be helpful in improving medication adherence. Further study is needed to reliably and sustainably improve medication adherence in children with asthma across the broader population; in some populations, alternate diagnoses, adjusting therapy, and other intervention may be required to improve asthma control and health.
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Affiliation(s)
- Heather Hoch De Keyser
- Breathing Institute, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
| | - Rachelle Ramsey
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Monica J Federico
- Breathing Institute, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
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14
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Harrison P, Duggan W, Preddy J, Moline A. Asthmatic children from lower-income families are less likely to own an individualised asthma action plan. J Paediatr Child Health 2020; 56:194-200. [PMID: 31243843 DOI: 10.1111/jpc.14553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/04/2019] [Accepted: 06/07/2019] [Indexed: 12/01/2022]
Abstract
AIM This study aimed to explore the relationship between indicators of socio-economic status (SES) and prescription of a paediatric individualised asthma action plan (IAAP), as well as compliance with that plan. METHODS Between May and September 2017, parents/carers of children aged 2-16 years who presented with acute respiratory symptoms and a prior diagnosis of asthma to the emergency department at one regional and one metropolitan hospital in NSW, Australia, were invited to participate in a questionnaire-based study. RESULTS A total of 175 eligible participants were identified, of which 113 completed the questionnaire. Eighty-seven children had been prescribed an IAAP (77%). Forty-nine parents/carers reported non-compliance with that plan (56.3%). Children from low- to middle-income families were significantly less likely to have a plan (P = 0.001). Being an only child was associated with greater IAAP compliance (P = 0.007) and better asthma control (P = 0.035). No significant relationship between other indicators of SES and rates of plan ownership or compliance was demonstrated. CONCLUSION Although relatively high in our study sample, IAAP ownership rates remain well below published guidelines. Given the income-based disparity in plan ownership, physicians must routinely prescribe plans to all asthmatics. Strategies to ensure IAAP ownership and promote their use, especially in the public health sector, would be valuable. Repeating a similar study with a larger sample size will allow more robust conclusions to be drawn regarding the impact of parental SES on compliance.
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Affiliation(s)
- Philippa Harrison
- Rural Clinical School, UNSW Medicine, New South Wales, Australia.,Department of Paediatrics, Wagga Wagga Rural Referral Hospital, Wagga Wagga, New South Wales, Australia.,Department of Paediatrics, St. George Hospital, Sydney, New South Wales, Australia
| | - William Duggan
- Rural Clinical School, UNSW Medicine, New South Wales, Australia.,Department of Paediatrics, Wagga Wagga Rural Referral Hospital, Wagga Wagga, New South Wales, Australia.,Department of Paediatrics, St. George Hospital, Sydney, New South Wales, Australia
| | - John Preddy
- Rural Clinical School, UNSW Medicine, New South Wales, Australia.,Department of Paediatrics, Wagga Wagga Rural Referral Hospital, Wagga Wagga, New South Wales, Australia.,Department of Paediatrics, St. George Hospital, Sydney, New South Wales, Australia
| | - Adrienne Moline
- Rural Clinical School, UNSW Medicine, New South Wales, Australia.,Department of Paediatrics, Wagga Wagga Rural Referral Hospital, Wagga Wagga, New South Wales, Australia.,Department of Paediatrics, St. George Hospital, Sydney, New South Wales, Australia
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15
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Abstract
PURPOSE OF REVIEW The goal of this review is to discuss strategies to prevent asthma exacerbations in children, focusing on recent advances in knowledge and understanding. RECENT FINDINGS Asthma exacerbations are common, and their prevention is an important goal to avoid detrimental impacts such as loss of disease control and lung function and significant healthcare costs. A number of strategies have been studied as tools for prevention of asthma exacerbations. Daily inhaled corticosteroids (ICSs) are effective for many children with asthma. However, alternative strategies such as intermittent ICS therapy, antileukotrienes, and biologics have been studied as means to lessen corticosteroid exposure. Further, recent studies have examined add-on strategies for children not controlled with ICS alone. Finally, personalizing therapy with targeted approaches has provided significant benefit to those with moderate-severe disease. SUMMARY Recent research highlights many potentially effective treatment strategies to prevent asthma exacerbations in children. We have reviewed and summarized the data on treatment approaches to help provide a better understanding of the methods that can be utilized. An individualized approach with careful monitoring is essential to identify the most effective strategies to prevent asthma exacerbations in each child.
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16
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Varricchi G, Marone G, Spadaro G, Russo M, Granata F, Genovese A, Marone G. Novel Biological Therapies in Severe Asthma: Targeting the Right Trait. Curr Med Chem 2019; 26:2801-2822. [PMID: 29318959 DOI: 10.2174/0929867325666180110094542] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 11/09/2017] [Accepted: 11/09/2017] [Indexed: 12/23/2022]
Abstract
Asthma is a heterogeneous disease characterized by chronic airway inflammation that results in a wide spectrum of clinical manifestations. Patients with severe asthma represent a substantial share of consumption of healthcare resources and hospitalization. Moreover, these patients are at risk of increased morbidity and mortality. Recently, several phenotypes and endotypes of asthma have been identified. The identification of specific subtypes of asthma is fundamental for optimizing the clinical benefit of novel treatments. Although in most patients the disease can be controlled by some combination of pharmacologic agents, in some 5-10% of patients the disease remains uncontrolled. Several monoclonal antibodies (mAbs) targeting pathogenetic molecules (e.g., IgE, IL-5, IL- 5Rα, IL-4, IL-13, TSLP) are currently available or under development for the treatment of different forms of severe type 2 asthma. The identification of diagnostic and predictive biomarkers (e.g., IgE, blood eosinophil count, FeNO, periostin, etc.) has revolutioned the field of targeted therapy in severe asthma. Monoclonal antibodies targeting Th2-driven inflammation are generally safe in adult patients with moderate-to-severe asthma. The long-term safety of these biologics is a relevant issue that should be addressed. Unfortunately, little is known about non-type 2 asthma. Further studies are needed to identify biomarkers to guide targeted therapies of different forms of non-type 2 asthma.
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Affiliation(s)
- Gilda Varricchi
- Department of Translational Medical Sciences (DISMET), University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Giancarlo Marone
- Department of Public Health, University of Naples Federico II, Naples, Italy.,Monaldi Hospital, Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences (DISMET), University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Michele Russo
- Department of Translational Medical Sciences (DISMET), University of Naples Federico II, Naples, Italy
| | - Francescopaolo Granata
- Department of Translational Medical Sciences (DISMET), University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Arturo Genovese
- Department of Translational Medical Sciences (DISMET), University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Gianni Marone
- Department of Translational Medical Sciences (DISMET), University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy.,Institute of Experimental Endocrinology and Oncology "Gaetano Salvatore", National Research Council (CNR), Naples, Italy
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17
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Dai X, Dharmage SC, Bowatte G, Waidyatillake NT, Perret JL, Hui J, Erbas B, Abramson MJ, Lowe AJ, Burgess JA, Svanes C, Lodge CJ. Interaction of Glutathione S-Transferase M1, T1, and P1 Genes With Early Life Tobacco Smoke Exposure on Lung Function in Adolescents. Chest 2019; 155:94-102. [PMID: 30616740 DOI: 10.1016/j.chest.2018.08.1079] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 07/14/2018] [Accepted: 08/24/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Glutathione S-transferase (GST) genes are involved in the management of oxidative stress in the lungs. We aimed to determine whether they modify the associations between early life smoke exposure and adverse lung health outcomes. METHODS The Melbourne Atopy Cohort study (a high-risk birth cohort) enrolled 620 children and followed them prospectively from birth. We recorded perinatal tobacco smoke exposure, asthma, and lung function at 12 (59%) and 18 years (66%) and genotyped for GSTM1, GSTT1, and GSTP1 (69%). RESULTS GST genotypes were found to interact with tobacco smoke exposure on lung function outcomes (P interaction ≤ .05). Only among children with GSTT1 null genotypes was exposure to mother's, father's, or parental tobacco smoke in early life associated with an increased risk of reductions in prebronchodilator (BD) FEV1 and FVC at both 12 and 18 years. These associations were not seen in children with GSTT1 present. Similarly, only among children with GSTM1 null genotypes was exposure to father's or parental smoking associated with reductions in pre- and post-BD FEV1 and FVC at 18 years. Only among children with Ile/Ile genotypes of GSTP1 was exposure to mother's smoking associated with increased risk of reduced FEV1 at 18 years, but this was not the case among children with Val/Val or Ile/Val genotypes. CONCLUSIONS Our study provides evidence of interaction between early tobacco smoke exposure and GST genotypes on lung function. Carriers of GST null mutations and GSTP1 Ile/Ile alleles may be more susceptible when exposed to tobacco smoke in early life. These findings support stronger recommendations to protect all infants from tobacco smoke exposure. TRIAL REGISTRY Australian and New Zealand Clinical Trials Registry; No.: ACTRN12609000734268; URL: http://www.anzctr.org.au/.
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Affiliation(s)
- Xin Dai
- Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Shyamali C Dharmage
- Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia; Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, VIC, Australia.
| | - Gayan Bowatte
- Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia; National Institute of Fundamental Studies, Kandy, Sri Lanka
| | - Nilakshi T Waidyatillake
- Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Jennifer L Perret
- Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Jennie Hui
- PathWest Laboratory Medicine of West Australia, Perth, WA, Australia; School of Population and Global Health and School of Pathology and Laboratory Medicine, The University of Western Australia, WA, Australia; Busselton Population Medical Research Institute, WA, Australia
| | - Bircan Erbas
- School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia; Centre for International Health, University of Bergen, Bergen, Norway
| | - Michael J Abramson
- School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Adrian J Lowe
- Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia; Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - John A Burgess
- Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Cecilie Svanes
- Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
| | - Caroline J Lodge
- Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
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18
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Marone G, Spadaro G, Braile M, Poto R, Criscuolo G, Pahima H, Loffredo S, Levi-Schaffer F, Varricchi G. Tezepelumab: a novel biological therapy for the treatment of severe uncontrolled asthma. Expert Opin Investig Drugs 2019; 28:931-940. [PMID: 31549891 DOI: 10.1080/13543784.2019.1672657] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Thymic stromal lymphopoietin (TSLP) is overexpressed in the airways of severe asthmatics and is an upstream cytokine that orchestrates inflammatory responses in asthma. TSLP exerts its effects by binding to a high affinity heteromeric receptor complex composed of TSLPR and IL-7Rα. An association of polymorphisms in TSLP with airway hyperresponsiveness, IgE, eosinophilia and asthma has been documented. TSLP has been implicated in asthma pathophysiology. Tezepelumab is a first-in-class human monoclonal antibody that binds to TSLP, thus inhibiting its interaction with TSLP receptor complex. Tezepelumab given as an add-on-therapy to patients with severe uncontrolled asthma has shown safety, tolerability and efficacy. Several trials are evaluating the long-term safety and the efficacy of tezepelumab in adults and adolescents with severe uncontrolled asthma.Areas covered: We provide an overview of the monoclonal antibody therapeutics market for severe uncontrolled asthma, examine the underlying pathophysiology that drives TSLP and discuss the use of tezepelumab for the treatment of severe uncontrolled asthma,Expert opinion: TSLP is a promising target for T2-high and perhaps some patients with T2-low asthma. The results of preliminary clinical trials are encouraging. Several unanswered questions concerning basic pathophysiological aspects of TSLP variants, the long-term safety and efficacy of tezepelumab with different phenotypes/endotypes of asthma should be addressed.
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Affiliation(s)
- Giancarlo Marone
- Department of Public Health, University of Naples Federico II, Naples, Italy.,Azienda Ospedaliera Ospedali dei Colli - Monaldi Hospital Pharmacy, Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Mariantonia Braile
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Remo Poto
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Gjada Criscuolo
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Hadas Pahima
- Pharmacology and Experimental Therapeutics Unit, School of Pharmacy, Institute for Drug Research, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Stefania Loffredo
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy.,Institute of Experimental Endocrinology and Oncology "G. Salvatore" (IEOS), National Research Council (CNR), Naples, Italy
| | - Francesca Levi-Schaffer
- Pharmacology and Experimental Therapeutics Unit, School of Pharmacy, Institute for Drug Research, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gilda Varricchi
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy.,Institute of Experimental Endocrinology and Oncology "G. Salvatore" (IEOS), National Research Council (CNR), Naples, Italy
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19
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Cushing CC, Fedele DA, Patton SR, McQuaid EL, Smyth JM, Prabhakaran S, Gierer S, Koskela-Staples N, Ortega A, Fleming KK, Nezu AM. Responsive Asthma Care for Teens (ReACT): development protocol for an adaptive mobile health intervention for adolescents with asthma. BMJ Open 2019; 9:e030029. [PMID: 31434777 PMCID: PMC6707700 DOI: 10.1136/bmjopen-2019-030029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Asthma is a leading cause of youth morbidity in the USA, affecting >8% of youth. Adherence to inhaled corticosteroids (ICS) can prevent asthma-related morbidity; however, the typical adolescent with asthma takes fewer than 50% of their prescribed doses. Adolescents are uniquely vulnerable to suboptimal asthma self-management due to still-developing executive functioning capabilities that may impede consistent self-regulation and weaken attempts to use problem solving to overcome barriers to ICS adherence. METHODS AND ANALYSIS The aims of this project are to improve adherence to ICS as an important step towards better self-management among adolescents aged 13-17 years diagnosed with asthma by merging the efficacious behaviour change strategies found in behavioural health interventions with scalable, adaptive mobile health (mHealth) technologies to create the Responsive Asthma Care for Teens programme (ReACT). ReACT intervention content will be developed through an iterative user-centred design process that includes conducting (1) one-on-one interviews with 20 teens with asthma; (2) crowdsourced feedback from a nationally representative panel of 100 adolescents with asthma and (3) an advisory board of youth with asthma, a paediatric pulmonologist and a behavioural health expert. In tandem, we will work with an existing technology vendor to programme ReACT algorithms to allow for tailored intervention delivery. We will conduct usability testing of an alpha version of ReACT with a sample of 20 target users to assess acceptability and usability of our mHealth intervention. Participants will complete a 4-week run-in period to monitor their adherence with all ReACT features turned off. Subsequently, participants will complete a 4-week intervention period with all ReACT features activated. The study started in October 2018 and is scheduled to conclude in late 2019. ETHICS AND DISSEMINATION Institutional review board approval was obtained at the University of Kansas and the University of Florida. We will submit study findings for presentation at national research conferences that are well attended by a mix of psychologists, allied health professionals and physicians. We will publish study findings in peer-reviewed journals read by members of the psychology, nursing and pulmonary communities.
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Affiliation(s)
- Christopher C Cushing
- Clinical Child Psychology Program and Schiefelbusch Institute for LifeSpan Studies, University of Kansas
| | - David A Fedele
- Department of Clinical & Health Psychology, University of Florida, Gainesville, FL
| | - Susana R Patton
- Department of Pediatrics, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Elizabeth L McQuaid
- Department of Psychiatry and Human Behavior, Brown University, Providence, Rhode Island, USA
| | - Joshua M Smyth
- Pennsylvania State University, University Park, Pennsylvania, USA
| | | | - Selina Gierer
- Division of Allergy and Immunology, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Adrian Ortega
- Clinical Child Psychology Program and Schiefelbusch Institute for LifeSpan Studies, University of Kansas
| | | | - Arthur M Nezu
- Department of Psychology, Drexel University, Philadelphia, Pennsylvania, USA
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20
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Pediatric asthma - moving ahead faster than ever. Curr Opin Allergy Clin Immunol 2019; 17:96-98. [PMID: 28225363 DOI: 10.1097/aci.0000000000000353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Sullivan PW, Ghushchyan V, Kavati A, Navaratnam P, Friedman HS, Ortiz B. Trends in Asthma Control, Treatment, Health Care Utilization, and Expenditures Among Children in the United States by Place of Residence: 2003-2014. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1835-1842.e2. [PMID: 30772478 DOI: 10.1016/j.jaip.2019.01.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 01/11/2019] [Accepted: 01/29/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Examining national trends in asthma treatment and control is essential to inform treatment and public health initiatives. OBJECTIVE Explore national trends in asthma control and treatment over time among children and those residing in poor-urban areas. METHODS This was an analysis of trends from 2003 to 2014 among children (aged 1-17 years) in the Medical Expenditure Panel Survey. Indicators of poor control included use of more than 3 canisters of short-acting β-agonists (SABAs) in 3 months, asthma attack, emergency department/inpatient hospitalization, and systemic corticosteroids. Treatment included inhaled corticosteroids, controller medications, SABAs, and greater than or equal to 0.7 ratio of controller-to-total prescriptions. Other measures included the number of asthma medications, outpatient visits, asthma-specific drug, and total expenditures per-patient-per-year. RESULTS There were 8.4 million children with asthma in the United States in 2014; 11.1% lived in poor-urban areas. There was a statistically significant decrease in the percentage of children using inhaled corticosteroids, controller medications, daily preventive medications, systemic corticosteroids, SABAs, more than 3 canisters of SABAs (in 3 months), overall asthma prescriptions, and outpatient visits. There was a significant increase in the percentage of children reporting having an asthma attack. Trends for children residing in poor-urban areas were compared with all others; however, limited data and variability in annual estimates prevent clear conclusions. CONCLUSIONS Results suggest lack of improvement in treatment and control since 2003 among children with asthma in the United States. There is significant room for improvement in asthma control and disease management among children.
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Affiliation(s)
| | - Vahram Ghushchyan
- University of Colorado, Denver, Colo; American University of Armenia, Yerevan, Armenia
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22
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Szefler SJ, Chipps B. Challenges in the treatment of asthma in children and adolescents. Ann Allergy Asthma Immunol 2018; 120:382-388. [PMID: 29625664 DOI: 10.1016/j.anai.2018.01.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 12/20/2017] [Accepted: 01/04/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Despite the availability of effective treatments, asthma control in children and adolescents remains inadequate and rates of health care use are high. This follow-up to a recent review (O'Byrne et al, Eur Respir J. 2017;50[3]) examines a number of challenges in current pediatric asthma management compared with that of an adult perspective and discusses possible alternative strategies that might improve pediatric asthma management and control. DATA SOURCES The evidence base for this review is limited because, historically, much of the research has been performed in adults. STUDY SELECTIONS Not applicable. RESULTS Pediatric asthma management is complicated by variability in asthma severity and control and difficulty in measuring pulmonary function and airway inflammation. Current challenges in pediatric asthma management include the recommended initial therapy treating only the symptoms rather than the underlying inflammation and switching to controller therapy only when asthma subsequently worsens. CONCLUSION Alternative strategies that might improve pediatric asthma management and control include replacement of short-acting β2-agonist relievers by an inhaled corticosteroid plus a fast-acting β2-agonist (short-acting β2-agonist or fast- and long-acting β2-agonist) combination at Global Initiative for Asthma step 1 or 2 to ensure that patients receive an inhaled corticosteroid whenever they feel the need for symptomatic relief. Such an approach could eliminate the problem of learned overuse or over-reliance on short-acting β2-agonist reliever medication and address the other challenges in current pediatric asthma management. Clinical studies in pediatric patients or large studies involving a proportion of pediatric patients are required to provide the supporting evidence needed to help advance such new approaches and improve asthma control from a pediatric perspective.
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Affiliation(s)
- Stanley J Szefler
- Pediatric Asthma Research Program and The Breathing Institute, Children's Hospital Colorado, University Colorado School of Medicine, Aurora, Colorado
| | - Bradley Chipps
- Capital Allergy & Respiratory Disease Center, Sacramento, California.
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23
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Britt RD, Thompson MA, Sasse S, Pabelick CM, Gerber AN, Prakash YS. Th1 cytokines TNF-α and IFN-γ promote corticosteroid resistance in developing human airway smooth muscle. Am J Physiol Lung Cell Mol Physiol 2018; 316:L71-L81. [PMID: 30335498 DOI: 10.1152/ajplung.00547.2017] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Corticosteroids (CSs) are commonly used to manage wheezing and asthma in pediatric populations. Although corticosteroids are effective in alleviating airway diseases, some children with more moderate-severe asthma phenotypes show CS resistance and exhibit significant airflow obstruction, persistent inflammation, and more frequent exacerbations. Previous studies have demonstrated that Th1 cytokines, such as TNF-α and IFN-γ, promote CS resistance in adult human airway smooth muscle (ASM). In the present study, using a human fetal ASM cell model, we tested the hypothesis that TNF-α/IFN-γ induces CS resistance. In contrast to TNF-α or IFN-γ alone, the combination of TNF-α/IFN-γ blunted the ability of fluticasone propionate (FP) to reduce expression of the chemokines CCL5 and CXCL10 despite expression of key anti-inflammatory glucocorticoid receptor target genes being largely unaffected by TNF-α/IFN-γ. Expression of the NF-κB subunit p65 and phosphorylation of Stat1 were elevated in cells treated with TNF-α/IFN-γ, an effect that remained in the presence of FP. siRNA knockdown studies demonstrated the effects of TNF-α/IFN-γ on increased p65 are mediated by Stat1, a transcription factor activated by IFN-γ. Expression of TNFAIP3, a negative regulator of NF-κB activity, was not altered by TNF-α/IFN-γ. However, the effects of TNF-α/IFN-γ were partially reduced by overexpression of TNFAIP3 but did not influence p65 expression. Together, these data suggest that IFN-γ augments the effects of TNF-α on chemokines by enhancing expression of key inflammatory pathways in the presence of CS. Interactions between TNF-α- and IFN-γ-mediated pathways may promote inflammation in asthmatic children resistant to CSs.
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Affiliation(s)
- Rodney D Britt
- Department of Physiology and Biomedical Engineering, Mayo Clinic , Rochester, Minnesota.,Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital , Columbus, Ohio.,Department of Pediatrics, The Ohio State University , Columbus, Ohio
| | - Michael A Thompson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic , Rochester, Minnesota
| | - Sarah Sasse
- Department of Medicine, National Jewish Health , Denver, Colorado
| | - Christina M Pabelick
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic , Rochester, Minnesota.,Department of Physiology and Biomedical Engineering, Mayo Clinic , Rochester, Minnesota
| | - Anthony N Gerber
- Department of Medicine, National Jewish Health , Denver, Colorado
| | - Y S Prakash
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic , Rochester, Minnesota.,Department of Physiology and Biomedical Engineering, Mayo Clinic , Rochester, Minnesota
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24
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Desager K, Vermeulen F, Bodart E. Adherence to asthma treatment in childhood and adolescence - a narrative literature review. Acta Clin Belg 2018; 73:348-355. [PMID: 29228891 DOI: 10.1080/17843286.2017.1409684] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES We provide a narrative literature review on surveys used to assess the level of medication adherence in children and adolescents with asthma, the attitudes of these patients and their parents toward asthma therapy, and their expectations concerning asthma and available treatment. METHODS A PubMed search and manual selection of the retrieved papers was conducted to identify studies using surveys or interviews that addressed one of the three topics of interest. RESULTS Adherence to asthma medication varies across age groups and with the type of measurement used. Levels of 49-71% were observed in children and adolescents by objective measurements. Subjective measurements overestimate the level of adherence compared to objective measurements. A considerable percentage of parents expressed fear of side effects of inhaled corticosteroids, although the impact of these concerns on adherence is unclear. Many adolescents and parents adapt inhaled corticosteroids use according to the prevalence of asthma symptoms, by reducing or eliminating controller medication in the absence of symptoms. Pediatric asthma patients and their parents tend to overestimate the level of asthma control, either by underestimating asthma severity or by assuming that a better control is not possible. The knowledge of parents and adolescents concerning asthma management is suboptimal; moreover, insufficient knowledge about inhaled corticosteroids was linked to poor adherence. CONCLUSION Medication adherence is crucial for a good control of asthma symptoms. Additional research concerning the triggers of non-adherence is still needed. Educating both the patients and their parents on proper asthma care might improve adherence.
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Affiliation(s)
- Kristine Desager
- Department of Pediatrics, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Françoise Vermeulen
- Department of Pediatrics, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Eddy Bodart
- Department of Pediatrics, Université Catholique de Louvain (UcL), CHU Dinant Godinne/UCL Namur, Yvoir, Belgium
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25
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Precision/Personalized Medicine in Allergic Diseases and Asthma. Arch Immunol Ther Exp (Warsz) 2018; 66:431-442. [PMID: 30251122 DOI: 10.1007/s00005-018-0526-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 09/16/2018] [Indexed: 12/21/2022]
Abstract
Like many other chronic diseases, every allergic patient has different characteristics based on clinical course, treatment responsiveness and disease outcomes, which are associated with the genetic and epigenetic control of molecular mechanisms and environment. This variability necessitates the establishment of patient-tailored and precision approaches in handling allergic disorders. Better understanding of the underlying pathophysiological mechanisms for the development of allergic disorders will provide more rationale strategies based on individual cases in controlling and treating these disorders. Endotyping, phenotyping, genotyping and theratyping, and biomarkers are keywords in this area and have been gaining lots of attention in the field of precision medicine, which aims to revolutionize patient care and develop better prevention and treatment strategies. In addition, precision health is a new concept that brings precise approaches to the scene for being healthy and prevention of allergic disease and asthma. The specialty of allergy has a leading role in the field, because allergen-specific immunotherapy started 105 years ago, and is historically a leading personalized/precision medicine approach in all medicine disciplines providing the possibility of cure in an individualized manner instead of conventional symptomatic treatments.
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26
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Abrams EM, Becker AB, Szefler SJ. Current State and Future of Biologic Therapies in the Treatment of Asthma in Children. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2018; 31:119-131. [PMID: 30283711 DOI: 10.1089/ped.2018.0901] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/26/2018] [Indexed: 02/06/2023]
Abstract
There is increasing recognition of phenotypic variability in pediatric asthma, providing the opportunity for a more personalized approach to therapy. Increasingly biologic therapies, in particular those targeting the "allergic" (or T helper 2) pathway, are being considered for children with severe asthma. However, there is a great deal of variability in the extent these biologic therapies have been studied in children, as well as efficacy of results thus far. The goal of this article is to review the mechanism of action, efficacy, and potential predictive and monitoring biomarkers of the biologic medications focusing on the pediatric population, in an effort to establish a more personalized approach to asthma in the pediatric population for the 21st century.
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Affiliation(s)
- Elissa M Abrams
- Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, Canada
| | - Allan B Becker
- Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, Canada
| | - Stanley J Szefler
- Department of Pediatrics, Section of Pulmonary Medicine, Breathing Institute, University of Colorado School of Medicine, Aurora, Colorado
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27
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Rhee H, Love T, Mammen J. Comparing Asthma Control Questionnaire (ACQ) and National Asthma Education and Prevention Program (NAEPP) asthma control criteria. Ann Allergy Asthma Immunol 2018; 122:58-64. [PMID: 30213611 DOI: 10.1016/j.anai.2018.09.448] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/15/2018] [Accepted: 09/05/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Adequate assessment of control is critical to asthma management. The Asthma Control Questionnaire (ACQ) and the National Asthma Education and Prevention Program (NAEPP) criteria are commonly used measures of asthma control. OBJECTIVE To examine the associations between the ACQ and NAEPP criteria and compare the validity in association with lung function, asthma exacerbation, and quality of life. METHODS The ACQ and the NAEPP criteria were administered to 373 adolescents with asthma aged 12 to 20 years. The 2 measures correlated with forced expiratory volume in 1 second (FEV1), asthma exacerbation (oral corticosteroid use, hospitalization, and emergency department [ED] use) in the past 12 months, and quality of life. RESULTS Agreement between the ACQ and NAEPP criteria was moderate (κ = 0.40-0.61). Neither of the 2 measures was a reliable predictor of FEV1 less than 80% because of the high rate of false-positive results for the ACQ (68%) and low sensitivity for the NAEPP (49%). The NAEPP identified more cases of uncontrolled asthma (84.6%) than the ACQ (64.6%). The ACQ was a significant predictor of recent oral corticosteroid use, hospitalization, and ED visits (area under the curve = 0.66, 0.66, and 0.64, respectively; P < .001), as was NAEPP (area under the curve = 0.63, 0.66, and 0.61, respectively; P < .001). Both measures were significantly associated with quality of life, and the associations were particularly strong for the ACQ (r = -0.87 for symptom subscale, r = -0.76 for activity subscale, and r = -0.78 for emotional function subscale). CONCLUSION Neither the ACQ nor the NAEPP appears to reliably predict lung function, whereas both measures reasonably associate with acute asthma exacerbation. The ACQ may be the superior measure in gauging the psychosocial effect of asthma control given its particularly strong associations with quality of life. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02293499.
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Affiliation(s)
- Hyekyun Rhee
- University of Rochester School of Nursing, Rochester, New York.
| | - Tanzy Love
- Department of Biostatistics, University of Rochester Medical Center, Rochester, New York
| | - Jennifer Mammen
- University of Rochester School of Nursing, Rochester, New York
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28
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Paw M, Wnuk D, Kądziołka D, Sęk A, Lasota S, Czyż J, Madeja Z, Michalik M. Fenofibrate Reduces the Asthma-Related Fibroblast-To-Myofibroblast Transition by TGF-Β/Smad2/3 Signaling Attenuation and Connexin 43-Dependent Phenotype Destabilization. Int J Mol Sci 2018; 19:ijms19092571. [PMID: 30158495 PMCID: PMC6163263 DOI: 10.3390/ijms19092571] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 08/21/2018] [Accepted: 08/27/2018] [Indexed: 12/26/2022] Open
Abstract
The activation of human bronchial fibroblasts by transforming growth factor-β1 (TGF-β1) leads to the formation of highly contractile myofibroblasts in the process of the fibroblast–myofibroblast transition (FMT). This process is crucial for subepithelial fibrosis and bronchial wall remodeling in asthma. However, this process evades current therapeutic asthma treatment strategies. Since our previous studies showed the attenuation of the TGF-β1-induced FMT in response to lipid-lowering agents (e.g., statins), we were interested to see whether a corresponding effect could be obtained upon administration of hypolipidemic agents. In this study, we investigated the effect of fenofibrate on FMT efficiency in populations of bronchial fibroblasts derived from asthmatic patients. Fenofibrate exerted a dose-dependent inhibitory effect on the FMT, even though it did not efficiently affect the expression of α-smooth muscle actin (α-SMA; marker of myofibroblasts); however, it considerably reduced its incorporation into stress fibers through connexin 43 regulation. This effect was accompanied by disturbances in the actin cytoskeleton architecture, impairments in the maturation of focal adhesions, and the fenofibrate-induced deactivation of TGF-β1/Smad2/3 signaling. These data suggest that fenofibrate interferes with myofibroblastic differentiation during asthma-related subepithelial fibrosis. The data indicate the potential application of fenofibrate in the therapy and prevention of bronchial remodeling during the asthmatic process.
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Affiliation(s)
- Milena Paw
- Faculty of Biophysics, Biochemistry and Biotechnology, Department of Cell Biology, Jagiellonian University, Gronostajowa 7, 30-378 Kraków, Poland.
| | - Dawid Wnuk
- Faculty of Biophysics, Biochemistry and Biotechnology, Department of Cell Biology, Jagiellonian University, Gronostajowa 7, 30-378 Kraków, Poland.
| | - Dominika Kądziołka
- Faculty of Biophysics, Biochemistry and Biotechnology, Department of Cell Biology, Jagiellonian University, Gronostajowa 7, 30-378 Kraków, Poland.
| | - Aleksandra Sęk
- Faculty of Biophysics, Biochemistry and Biotechnology, Department of Cell Biology, Jagiellonian University, Gronostajowa 7, 30-378 Kraków, Poland.
- Nencki Institute of Experimental Biology, Laboratory of Intracellular Ion Channels, 02-093 Warsaw, Poland.
| | - Sławomir Lasota
- Faculty of Biophysics, Biochemistry and Biotechnology, Department of Cell Biology, Jagiellonian University, Gronostajowa 7, 30-378 Kraków, Poland.
| | - Jarosław Czyż
- Faculty of Biophysics, Biochemistry and Biotechnology, Department of Cell Biology, Jagiellonian University, Gronostajowa 7, 30-378 Kraków, Poland.
| | - Zbigniew Madeja
- Faculty of Biophysics, Biochemistry and Biotechnology, Department of Cell Biology, Jagiellonian University, Gronostajowa 7, 30-378 Kraków, Poland.
| | - Marta Michalik
- Faculty of Biophysics, Biochemistry and Biotechnology, Department of Cell Biology, Jagiellonian University, Gronostajowa 7, 30-378 Kraków, Poland.
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29
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Akdis CA, Ballas ZK. Precision medicine and precision health: Building blocks to foster a revolutionary health care model. J Allergy Clin Immunol 2018; 137:1359-61. [PMID: 27155031 DOI: 10.1016/j.jaci.2016.03.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 03/28/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research, University of Zurich, Christine Kühne-Center for Allergy Research and Education, Davos, Switzerland.
| | - Zuhair K Ballas
- Internal Medicine, University of Iowa, and Iowa City VA Medical Center, Iowa City, Iowa
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30
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Generoso A, Muglia-Chopra C, Oppenheimer J. Prospects for Monoclonal Antibody Therapy in Pediatric Asthma. Curr Allergy Asthma Rep 2018; 18:45. [PMID: 29992472 DOI: 10.1007/s11882-018-0799-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The profile of biologic therapies for asthma is growing rapidly. We discuss how to match the proper pediatric patient with the most effective therapy. RECENT FINDINGS Currently available biologic therapies are most effective in patients with T2 high asthma. Newer drugs are currently being studied which target TSLP and interleukin 33. These newer drugs may provide options for asthmatics who do not respond to the current anti-IgE, anti-IL5, and anti-IL4/13 therapies. Asthma is a heterogeneous disease which can be driven by different inflammatory mediators in different patients. To select the most effective biologic therapy for a pediatric patient, the asthma phenotype must first be determined. The steep cost of biologics limits their use, which makes proper pairing of patient to therapy even more crucial. Presently, several therapies exist for T2 high asthma, but it is hoped in the future that development of drugs effective for T2 low asthmatics will be available as well.
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Affiliation(s)
- August Generoso
- Rutgers New Jersey Medical School, The State University of New Jersey, 90 Bergen Street, Newark, NJ, 07103, USA
| | - Christine Muglia-Chopra
- Rutgers New Jersey Medical School, The State University of New Jersey, 90 Bergen Street, Newark, NJ, 07103, USA
| | - John Oppenheimer
- Rutgers New Jersey Medical School, The State University of New Jersey, 90 Bergen Street, Newark, NJ, 07103, USA.
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31
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Yeh YL, Su MW, Chiang BL, Yang YH, Tsai CH, Lee YL. Genetic profiles of transcriptomic clusters of childhood asthma determine specific severe subtype. Clin Exp Allergy 2018; 48:1164-1172. [PMID: 29758111 DOI: 10.1111/cea.13175] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 04/24/2018] [Accepted: 05/02/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Previous studies have defined transcriptomic subtypes of adult asthma using samples of induced sputum and bronchial epithelium; however, those procedures are not readily applicable in the clinic, especially for childhood asthma. OBJECTIVE We aim to dissect the transcriptomic clusters of childhood asthma using highly variably expressed genes of peripheral blood mononuclear cells (PBMC) among patients. METHODS Gene expression of PBMC from 133 asthmatic children and 11 healthy controls was measured with Illumina microarrays. We applied the k-means clustering algorithm of 2048 genes to assign asthmatic children into clusters. Genes with differential expression between asthma clusters and healthy controls were used to investigate whether they could identify severe asthma of children and adults. RESULTS We identified 3 asthma clusters with distinct inflammatory profiles in peripheral blood. Cluster 1 had the highest eosinophil count. Cluster 2 showed lower counts of both eosinophils and neutrophils. Cluster 3 had the highest neutrophil count and the poorest treatment control. Compared with other patients, Cluster 3 exhibited a unique gene expression pattern which was associated with changes in the glucocorticoid signalling and activation of the T helper 1/T helper 17 (TH 1/TH 17) immune pathways. In the validation studies, an 84-gene signature could identify severe asthma in children on leucocytes, as well as severe asthma in adults on CD8+ T cells. CONCLUSIONS AND CLINICAL RELEVANCE Gene expression profiling of PBMC is useful for the identification of TH 1/TH 17-mediated asthma with poor treatment control. PBMC and CD8+ T cells could be important targets for the investigation and identification of severe asthma.
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Affiliation(s)
- Y-L Yeh
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan.,School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - M-W Su
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - B-L Chiang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Y-H Yang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - C-H Tsai
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Y L Lee
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
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32
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Miller GE, Chen E, Shalowitz MU, Story RE, Leigh AKK, Ham P, Arevalo JMG, Cole SW. Divergent transcriptional profiles in pediatric asthma patients of low and high socioeconomic status. Pediatr Pulmonol 2018. [PMID: 29528197 PMCID: PMC5992048 DOI: 10.1002/ppul.23983] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
AIM There are marked socioeconomic disparities in pediatric asthma control, but the molecular origins of these disparities are not well understood. To fill this gap, we performed genome-wide expression profiling of monocytes and T-helper cells from pediatric asthma patients of lower and higher socioeconomic status (SES). METHOD Ninety-nine children with asthma participated in a cross-sectional assessment. Out of which 87% were atopic, and most had disease of mild (54%) or moderate (29%) severity. Children were from lower-SES (n = 49; household income <$50 000) or higher-SES (n = 50; household income >$140 000) families. Peripheral blood monocytes and T-helper cells were isolated for genome-wide expression profiling of mRNA. RESULTS Lower-SES children had worse asthma quality of life relative to higher-SES children, by both their own and their parents' reports. Although the groups had similar disease severity and potential confounds were controlled, their transcriptional profiles differed notably. The monocytes of lower-SES children showed transcriptional indications of up-regulated anti-microbial and pro-inflammatory activity. The T-helper cells of lower-SES children also had comparatively reduced expression of genes encoding γ-interferon and tumor necrosis factor-α, cytokines that orchestrate Type 1 responses. They also showed up-regulated activity of transcription factors that polarize cells towards Type 2 responses and promote Th17 cell maturation. CONCLUSION Collectively, these patterns implicate pro-inflammatory monocytes and Type 2 cytokine activity as mechanisms contributing to worse asthma control among lower-SES children.
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Affiliation(s)
- Gregory E Miller
- Department of Psychology and Institute for Policy Research, Northwestern University, Evanston, Illinois
| | - Edith Chen
- Department of Psychology and Institute for Policy Research, Northwestern University, Evanston, Illinois
| | - Madeleine U Shalowitz
- NorthShore University Health Systems, University of Chicago, Pritzker School of Medicine, Chicago, Illinois
| | - Rachel E Story
- NorthShore University Health Systems, University of Chicago, Pritzker School of Medicine, Chicago, Illinois
| | - Adam K K Leigh
- Department of Psychology and Institute for Policy Research, Northwestern University, Evanston, Illinois
| | - Paula Ham
- Department of Psychology and Institute for Policy Research, Northwestern University, Evanston, Illinois
| | - Jesusa M G Arevalo
- Division of Hematology-Oncology, UCLA AIDS Institute, Molecular Biology Institute, Jonsson Comprehensive Cancer Center, and Norman Cousins Center, UCLA School of Medicine, Los Angeles, California
| | - Steve W Cole
- Division of Hematology-Oncology, UCLA AIDS Institute, Molecular Biology Institute, Jonsson Comprehensive Cancer Center, and Norman Cousins Center, UCLA School of Medicine, Los Angeles, California
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33
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Sullivan PW, Ghushchyan V, Kavati A, Navaratnam P, Friedman HS, Ortiz B. Health Disparities Among Children with Asthma in the United States by Place of Residence. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:148-155. [PMID: 29782937 DOI: 10.1016/j.jaip.2018.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/08/2018] [Accepted: 05/03/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Children residing in poor-urban areas may have greater asthma morbidity. It is unclear whether this is due to individual characteristics such as race and ethnicity or place of residence. OBJECTIVE Assess indicators of control and treatment by residence. METHODS This was a cross-sectional analysis of children (aged 1-17 years) in the 2000-2014 Medical Expenditure Panel Survey (MEPS). Indicators of poor control included use of more than 3 canisters of short-acting beta agonist (SABA) in 3 months, asthma attack, and emergency department (ED) or inpatient (IP) visit during the year. Treatment measures included use of controller medications and a ratio of controller-to-total prescriptions of 0.7 or more. RESULTS There were 15,052 children with asthma in the MEPS 2000-2014 data, reflecting 8.4 million children in 2014. After controlling for covariates, children with asthma residing in poor-urban areas had lower odds of using controller medications (odds ratio [OR] = 0.77), having a controller-to-total ratio of 0.7 or more (OR = 0.75), and reporting an asthma attack (OR = 0.75) and higher odds of having an ED/IP visit (OR = 1.3) compared with those living elsewhere. Black race and Hispanic ethnicity were associated with greater odds of excessive SABA use (OR = 2.11) and ED/IP visits (OR = 2.03) and lower odds of controller-to-total ratio of 0.07 or more (OR = 0.50). CONCLUSIONS Poor-urban residence may be independently associated with asthma control and treatment even after controlling for individual characteristics such as race and ethnicity. Future research is needed to understand the sources of these geographic health disparities to more successfully target public health interventions.
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Affiliation(s)
| | - Vahram Ghushchyan
- University of Colorado, Denver, Colo; American University of Armenia, Yerevan, Armenia
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34
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Lenney W, Bush A, Fitzgerald DA, Fletcher M, Ostrem A, Pedersen S, Szefler SJ, Zar HJ. Improving the global diagnosis and management of asthma in children. Thorax 2018. [PMCID: PMC6035489 DOI: 10.1136/thoraxjnl-2018-211626] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Asthma is the most common chronic condition in children worldwide. It affects daytime activities, sleep and school attendance and causes anxiety to parents, families and other carers. The quality of asthma diagnosis and management globally still needs substantial improvement. From infancy to the teenage years, there are age-specific challenges, including both underdiagnosis and overdiagnosis with stigma-related barriers to treatment in some cultures and in adolescents. Guidelines are increasingly evidence based, but their impact on improving outcomes has been negligible in many parts of the world, often due to lack of implementation. New thinking is needed to enable substantial improvements in outcomes. The disease varies globally and plans will need to differ for individual countries or places where region-specific barriers prevent optimal care. A wide selection of educational activities is needed, including community-targeted initiatives, to engage with families. The Paediatric Asthma Project Plan has been initiated to strengthen diagnosis and management of asthma. This encompasses a vision for the next 10–15 years, building on the knowledge and experience from previous educational projects. It will take into account the educational needs of patients, carers and healthcare professionals as well as the accessibility and affordability of medication, particularly in low and middle-income countries where the prevalence of asthma is rising more rapidly. This overview presents a first step for those involved in the diagnosis and management of childhood asthma to strengthen care for children globally.
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Affiliation(s)
- Warren Lenney
- Department of Child Health, Keele University, Stoke-on-Trent, UK
- Department of Child Health, Royal Stoke University Hospital (RSUH), Stoke-on-Trent, UK
- Global Respiratory Franchise, GlaxoSmithKline, Brentford, London, UK
| | - Andrew Bush
- Paediatrics, Imperial College London, London, UK
- Paediatrics, National Heart and Lung Institute, London, UK
- Paediatrics, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Dominic A Fitzgerald
- Sydney Medical School, Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Respiratory Medicine, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Monica Fletcher
- Global Respiratory Franchise, GlaxoSmithKline, Brentford, London, UK
- Asthma UK Centre for Applied Research (AUKCAR), University of Edinburgh, Edinburgh, UK
| | | | - Soren Pedersen
- Pediatric Research Unit, Kolding Hospital, University of Southern Denmark, Kolding, Denmark
| | - Stanley J Szefler
- Pediatric Asthma Research Program, Section of Pediatric Pulmonary Medicine, Breathing Institute, Children’s Hospital Colorado, Aurora, Colorado, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
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35
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Szefler SJ. Asthma across the lifespan: Time for a paradigm shift. J Allergy Clin Immunol 2018; 142:773-780. [PMID: 29627424 DOI: 10.1016/j.jaci.2018.03.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/12/2018] [Accepted: 03/23/2018] [Indexed: 12/25/2022]
Abstract
We have a unique opportunity to significantly reduce the worldwide burden of asthma in children and affect respiratory outcomes in adults. However, this will require a paradigm shift that is directed at altering the natural history of asthma, reducing asthma exacerbations, and preventing long-term adverse outcomes of childhood asthma. Attention should continue to be directed toward minimizing risk, as well as impairment, with a goal to achieve optimal control. Based on several National Institutes of Health studies conducted over the last 10 years, we now have the tools necessary to accomplish this goal. The tools include assessment of lung function over time or defining trajectories of lung growth, the Composite Asthma Severity Index score, a panel of useful biomarkers, the Seasonal Asthma Exacerbation Prediction Index score, and rapidly advancing technology that includes adherence monitoring. Future guideline revisions should consider incorporating recommendations to follow spirometry over time and defining trajectories of lung growth to assess risk for reduced lung growth and early decline, asthma burden by using biomarkers to select and monitor therapy, assessment of social determinants of health, evaluation of risk for seasonal exacerbations, and consideration of electronic adherence monitoring for difficult-to-manage asthma. Guidelines should continue to include a core dedicated to the diagnosis and treatment of intermittent and mild and moderate persistent asthma and include additional sections dedicated to the management of severe asthma.
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Affiliation(s)
- Stanley J Szefler
- Breathing Institute and Pulmonary Medicine Section, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo.
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36
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Abstract
Asthma is one of the most common chronic diseases in children, with a high proportion of patients demonstrating poor control despite the availability of disease management guidelines. Global Initiative for Asthma guidelines include tiotropium as an add-on therapy option at Steps 4 and 5 in patients aged ≥ 12 years with a history of exacerbations, and tiotropium delivered via the Respimat® Soft Mist™ Inhaler has recently been approved for use as once-daily maintenance therapy for children with asthma over the age of 6 years in the USA. A large clinical trial program has been conducted in children, adolescents, and adults across the spectrum of asthma severity. Findings from these clinical studies and pooled analyses in children and adolescents with symptomatic moderate or severe asthma have demonstrated that tiotropium Respimat® as add-on to inhaled corticosteroids, with or without other maintenance therapies, is a well-tolerated and efficacious bronchodilator, showing improved lung function and trends towards improved asthma control, mirroring findings in adult studies. This review discusses the evidence to date for tiotropium Respimat® for the management of asthma in adolescents and children with symptomatic moderate and severe asthma, and considers the challenges of asthma management in these patients. Factors affecting this population group, such as poor adherence, underreporting of symptoms, and social and psychological issues, are highlighted, along with the need for active review and management of treatment to help achieve optimal control.
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Affiliation(s)
- Eckard Hamelmann
- Children's Center Bethel, Evangelisches Klinikum Bethel GmbH, Grenzweg 10, 33617, Bielefeld, Germany.
| | - Stanley J Szefler
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, USA
- Breathing Institute, Children's Hospital Colorado, Aurora, USA
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Bruggers CS, Baranowski S, Beseris M, Leonard R, Long D, Schulte E, Shorter A, Stigner R, Mason CC, Bedrov A, Pascual I, Bulaj G. A Prototype Exercise-Empowerment Mobile Video Game for Children With Cancer, and Its Usability Assessment: Developing Digital Empowerment Interventions for Pediatric Diseases. Front Pediatr 2018; 6:69. [PMID: 29686977 PMCID: PMC5900044 DOI: 10.3389/fped.2018.00069] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 03/08/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Medical advances continue to improve morbidity and mortality of serious pediatric diseases, including cancer, driving research addressing diminished physical and psychological quality of life in children with these chronic conditions. Empowerment enhances resilience and positively influences health, disease, and therapy understanding. We describe the development and usability assessment of a prototype Empower Stars! mobile video game grounded in behavioral and exercise theories with the purpose of coupling physical exercise with empowerment over disease in children with cancer. METHODS Academic faculty, health-care providers, and community video game developers collaborated in this project. The iPadAir was selected as a delivery platform for its accelerometer and gyroscope features facilitating exercise design. Unity multiplatform technology provided animation and audiovisual features for immediate player feedback. Javascript, C#, Photoshop, Flash, and SketchUp were used for coding, creating graphical assets, Sprite sheets, and printing files, respectively. 3D-printed handles and case backing were used to adapt the iPad for physical exercise. Game usability, engagement, and enjoyment were assessed via a multilevel study of children undergoing cancer chemotherapy, their parents, and pediatric cancer health-care providers. Feedback crucial for ongoing game development was analyzed. RESULTS A prototype Empower Stars! mobile video game was developed for children 7-14 years old with cancer. Active, sedentary, educational, and empowerment-centered elements intermix for 20 min of exercise within a 30 min "one-day treatment" gameplay session involving superheroes, space exploration, metaphorical cancer challenges, life restoration on a barren planet, and innumerable star rewards. No player "dies." Usability assessment data analyses showed widespread enthusiasm for integrating exercise with empowerment over cancer and the game itself. Favorite elements included collecting star rewards and planet terraforming. Traveling in space and the Healthy Food Choice game were least liked. The need for improved gameplay instructions was expressed by all groups. The usability study provided essential feedback for converting the prototype into alpha version of Empower Stars! CONCLUSION Adapting exercise empowerment-promoting video game technology to mobile platforms facilitates usability and widespread dissemination for children with cancer. We discuss broader therapeutic applicability in diverse chronic pediatric diseases, including obesity, asthma, cystic fibrosis, diabetes, and juvenile idiopathic arthritis.
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Affiliation(s)
- Carol S Bruggers
- Division of Hematology-Oncology, Department of Pediatrics, University of Utah, Salt Lake City, UT, United States.,Primary Children's Hospital, Salt Lake City, UT, United States
| | | | | | | | - Derek Long
- Spy Hop Youth Media, Salt Lake City, UT, United States
| | | | | | - Rowan Stigner
- Spy Hop Youth Media, Salt Lake City, UT, United States
| | - Clinton C Mason
- Division of Hematology-Oncology, Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Alisa Bedrov
- Division of Hematology-Oncology, Department of Pediatrics, University of Utah, Salt Lake City, UT, United States.,Department of Medicinal Chemistry, College of Pharmacy, University of Utah, Salt Lake City, UT, United States
| | - Ian Pascual
- Division of Hematology-Oncology, Department of Pediatrics, University of Utah, Salt Lake City, UT, United States.,Department of Medicinal Chemistry, College of Pharmacy, University of Utah, Salt Lake City, UT, United States.,Juan Diego Catholic High School, Draper, UT, United States
| | - Grzegorz Bulaj
- Department of Medicinal Chemistry, College of Pharmacy, University of Utah, Salt Lake City, UT, United States
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Abstract
Biomarkers have been critical for studies of disease pathogenesis and the development of new therapies in severe asthma. In particular, biomarkers of type 2 inflammation have proven valuable for endotyping and targeting new biological agents. Because of these successes in understanding and marking type 2 inflammation, lack of knowledge regarding non-type 2 inflammatory mechanisms in asthma will soon be the major obstacle to the development of new treatments and management strategies in severe asthma. Biomarkers can play a role in these investigations as well by providing insight into the underlying biology in human studies of patients with severe asthma.
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Abstract
As new therapies for pediatric asthma are approved by the Food and Drug Administration, clinicians should be aware of their benefits and limitations. Accompanying these therapies are potential obstacles, including the delivery of inhaled therapies and age-specific issues regarding implementation and adherence. New insights are being added to well-established controller medications, including inhaled corticosteroids and long-acting β-agonists, while new medications previously approved in adults, including tiotropium and biologics, are now being evaluated for use in children. These drugs can be useful additive therapies to treat patients who are currently not responding to guidelines-based therapy.
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Sullivan PW, Ghushchyan V, Navaratnam P, Friedman HS, Kavati A, Ortiz B, Lanier B. The national burden of poorly controlled asthma, school absence and parental work loss among school-aged children in the United States. J Asthma 2017; 55:659-667. [PMID: 28981368 DOI: 10.1080/02770903.2017.1350972] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The degree of poorly controlled asthma and its association with missed school days and parental missed work days is not well understood. METHODS This was a retrospective analysis of missed school days and missed work days for school-aged children (SAC; aged 6-17) and their caregivers in the nationally representative 2007-2013 Medical Expenditure Panel Survey (MEPS). Indicators of poor asthma control included: exacerbation in previous 12 months; use of >3 canisters of short-acting beta agonist (SABA) in 3 months; and annual asthma-specific (AS) Emergency Department (ED) or inpatient (IP) visits. Negative binomial regression was used for missed school days, and a Heckman two-step selection model was used for missed work days. All analyses controlled for sociodemographics and other covariates. RESULTS There were 44,320 SAC in MEPS, of whom 5,890 had asthma. SAC with asthma and an indicator of poor control missed more school days than SAC without asthma: exacerbation (1.8 times more; p < 0.001); >3 canisters SABA (2.7 times more; p < 0.001) and ED/IP visit (3.8 times more; p < 0.001). The parents/caregivers of SAC with asthma and an exacerbation missed 1.2 times more work days (p < 0.05), while those with SAC with asthma and an ED/IP visit missed 1.8 times more work days (p < 0.01) than the parents of SAC without asthma. CONCLUSIONS This study provides evidence of the significant national burden of poorly controlled asthma due to missed school and work days in the United States. More effective and creative asthma management strategies, with collaboration across clinical, community and school-based outreach, may help address this burden.
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Affiliation(s)
- P W Sullivan
- a Rueckert-Hartman College for Health Professions , Regis University School of Pharmacy , Denver , CO , USA
| | - V Ghushchyan
- b Pharmaceutical Outcomes Research , University of Colorado , Denver CO , USA.,c American University of Armenia , Yerevan , Armenia
| | | | | | - A Kavati
- e Novartis Pharmaceuticals Corporation , East Hanover , NJ , USA
| | - B Ortiz
- e Novartis Pharmaceuticals Corporation , East Hanover , NJ , USA
| | - B Lanier
- f Department Pediatrics/Immunology , University of North Texas , Fort Worth , TX , USA
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Asthma guidelines: the Global Initiative for Asthma in relation to national guidelines. Curr Opin Allergy Clin Immunol 2017; 17:99-103. [PMID: 28118238 DOI: 10.1097/aci.0000000000000346] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW To compare and contrast national asthma guidelines with the Global Initiative for Asthma (GINA) strategy for asthma management and prevention. RECENT FINDINGS The common goal of GINA and national asthma guidelines is to improve asthma care using the best evidence available from published data. This evidence-based approach has evolved from an initial perspective of expert opinion but with that evolution has not always considered the breadth of asthma phenotypes. GINA and national guidelines differ in a number of ways. GINA reviews available data and updates the core document and recommendations based on the latest data on a yearly basis to offer local, regional and national guidelines materials needed for knowledge mobilization. It remains the purview of those organizations to structure and implement those locally appropriate guidelines. SUMMARY Both GINA and national guidelines have furthered asthma care to narrow the care gap from what is known to how asthma care is delivered, hopefully in a more directed, personalized manner. As well, both GINA and national guidelines have helped to shape the direction of research for the future benefit of children and their families.
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Incorporating technology to advance asthma controller adherence. Curr Opin Allergy Clin Immunol 2017; 17:153-159. [PMID: 28118240 DOI: 10.1097/aci.0000000000000343] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Technological innovations, including text messaging, smart phone applications, and electronic monitoring devices, aimed at improving asthma controller adherence are being rapidly introduced both into clinical care and directly marketed to patients. This review analyzes recent clinical trials implementing these interventions, with a focus on their benefits and shortcomings. RECENT FINDINGS Poor medication adherence continues to exert significant morbidity on patients with asthma. Objective, real-time measures to monitor adherence can overcome the limitations of prior methods, including self-report and prescription refills. Technological advances, especially those incorporating reminder systems, have demonstrated improved controller adherence. The increased adherence in these trials has not translated into consistent clinical improvement, including reducing hospitalizations, emergency department visits, and asthma exacerbations, possibly secondary to study design and poor inhalation technique. SUMMARY Novel monitoring and reminder technology can augment patient medication adherence and provide clues to management before escalating therapy. Further studies are needed to investigate the overarching clinical impact of this technology, especially as it grows into routine clinical practice.
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Sullivan PW, Ghushchyan V, Navaratnam P, Friedman HS, Kavati A, Ortiz B, Lanier B. National Prevalence of Poor Asthma Control and Associated Outcomes Among School-Aged Children in the United States. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:536-544.e1. [PMID: 28847656 DOI: 10.1016/j.jaip.2017.06.039] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/21/2017] [Accepted: 06/23/2017] [Indexed: 01/24/2023]
Abstract
BACKGROUND The degree of asthma control among school-aged children (SAC) nationally is not well understood. OBJECTIVE The objective of this study was to characterize poor control among SAC (aged 6-17 years) in the United States. METHODS This was a retrospective analysis of the 2007-2013 Medical Expenditure Panel Survey. Indicators of poor control included exacerbation in previous year; use of >3 canisters of short-acting β-agonist (SABA) in 3 months; and asthma-specific (AS) emergency department (ED) or inpatient (IP) visits. Treatment indicators included daily controller medication and peak flow meter use. Negative binomial regression was used for health resource utilization (HRU); generalized linear models with log-link were used for health care expenditures. RESULTS There were 44,320 SAC, of whom 5,890 had asthma. The prevalence of poor control and treatment among SAC with asthma were as follows: exacerbation (59%), >3 canisters of SABA (4%), ED/IP visit (3%), daily controller (19%), peak flow (12%). In 2013, 3.4 million SAC had an asthma exacerbation and 200,000 had an AS ED/IP visit. SAC with asthma and an exacerbation had 18.9 times more annual AS ED visits (and 43.3 times more AS hospitalizations) than SAC with asthma but no exacerbation. SAC with asthma and an indicator of poor control incurred greater annual all-cause expenditures than SAC without asthma ($US 2015): $1,144 (exacerbation), $1,859 (≥3 canisters of SABA), and $3,063 (ED/IP visit). Use of daily controller medication was low even among SAC with poor control (27% to 61%). CONCLUSION Renewed and vigilant asthma management and treatment is necessary to mitigate the current and long-term public health effects and expenditures associated with poor asthma control.
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Affiliation(s)
- Patrick W Sullivan
- Department of Pharmacy Practice, Regis University School of Pharmacy, Denver, Colo.
| | - Vahram Ghushchyan
- Department of Clinical Pharmacy, University of Colorado, Denver, Colo; College of Business and Economics, American University of Armenia, Yerevan, Armenia
| | | | | | | | | | - Bobby Lanier
- Department of Pediatrics, University of North Texas, Fort Worth, Texas
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Rowe RK, Gill MA. Effects of Allergic Sensitization on Antiviral Immunity: Allergen, Virus, and Host Cell Mechanisms. Curr Allergy Asthma Rep 2017; 17:9. [PMID: 28233152 DOI: 10.1007/s11882-017-0677-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Multiple clinical and epidemiological studies demonstrate links between allergic sensitization and virus-induced atopic disease exacerbations. This review summarizes the recent findings regarding allergen, viral, and host cellular mechanisms relevant to these observations. RECENT FINDINGS Recent studies have focused on the molecular pathways and genetic influences involved in allergen-mediated inhibition of innate antiviral immune responses. Multiple tissue and cell types from atopic individuals across the atopy spectrum exhibit deficient interferon responses to a variety of virus infections. Impairment in barrier function, viral RNA and DNA recognition by intracellular sensing molecules, and dysregulation of signaling components are broadly affected by allergic sensitization. Finally, genetic predisposition by numerous nucleotide polymorphisms also impacts immune pathways and potentially contributes to virus-associated atopic disease pathogenesis. Allergen-virus interactions in the setting of atopy involve complex tissue and cellular mechanisms. Future studies defining the pathways underlying these interactions could uncover potential therapeutic targets. Available data suggest that therapies tailored to restore specific components of antiviral responses will likely lead to improved clinical outcomes in allergic disease.
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Affiliation(s)
- Regina K Rowe
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390-9063, USA
| | - Michelle A Gill
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390-9063, USA. .,Department of Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USA. .,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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45
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Tan HTT, Sugita K, Akdis CA. Novel Biologicals for the Treatment of Allergic Diseases and Asthma. Curr Allergy Asthma Rep 2017; 16:70. [PMID: 27613653 DOI: 10.1007/s11882-016-0650-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW The development of biological therapies has rapidly progressed during the last few years, and major advances were reported for the treatment of allergic diseases, such as atopic dermatitis, allergic rhinitis, urticaria, food allergy, and asthma. Here, we review biologicals targeting the type 2 immune response involving Th2 cells, type 2 innate lymphoid cells, natural killer T cells, mast cells, basophils, and epithelial cells, such as IL-4, IL-5, IL-13, IL-31, tumor necrosis factor alpha (TNF-α), and thymic stromal lymphopoietin (TSLP). RECENT FINDINGS The biologicals that have been currently approved for asthma are omalizumab targeting IgE and reslizumab and mepolizumab targeting interleukin (IL)-5. Many other monoclonal antibodies are currently in various phases of clinical development. The new biological therapies for allergic diseases will eventually be tailored to the endotypes of these diseases and the identification of novel biomarkers. Further development of novel biologicals for the treatment of allergic diseases and asthma will be possible upon improved understanding of mechanisms of allergic diseases. Accordingly, further refinement of endotypes of allergen-specific and non-specific type 2 immune response and related inflammatory mediators is needed for optimal treatment of allergic diseases.
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Affiliation(s)
- Hern-Tze Tina Tan
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos Platz, Switzerland.,Department of Immunology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Kazunari Sugita
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos Platz, Switzerland.,Christine Kühne-Center for Allergy Research and Education, Davos, Switzerland.,Division of Dermatology, Department of Medicine of Sensory and Motor Organs, Tottori University Faculty of Medicine, Yonago, Japan
| | - Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos Platz, Switzerland. .,Christine Kühne-Center for Allergy Research and Education, Davos, Switzerland.
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46
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Liu AH, Anderson WC, Dutmer CM, Searing DA, Szefler SJ. Advances in asthma 2015: Across the lifespan. J Allergy Clin Immunol 2017; 138:397-404. [PMID: 27497278 DOI: 10.1016/j.jaci.2016.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/21/2016] [Accepted: 06/23/2016] [Indexed: 12/19/2022]
Abstract
In 2015, progress in understanding asthma ranged from insights to asthma inception, exacerbations, and severity to advancements that will improve disease management throughout the lifespan. 2015's insights to asthma inception included how the intestinal microbiome affects asthma expression with the identification of specific gastrointestinal bacterial taxa in early infancy associated with less asthma risk, possibly by promoting regulatory immune development at a critical early age. The relevance of epigenetic mechanisms in regulating asthma-related gene expression was strengthened. Predicting and preventing exacerbations throughout life might help to reduce progressive lung function decrease and disease severity in adulthood. Although allergy has long been linked to asthma exacerbations, a mechanism through which IgE impairs rhinovirus immunity and underlies asthma exacerbations was demonstrated and improved by anti-IgE therapy (omalizumab). Other key molecular pathways underlying asthma exacerbations, such as cadherin-related family member 3 (CDHR3) and orosomucoid like 3 (ORMDL3), were elucidated. New anti-IL-5 therapeutics, mepolizumab and reslizumab, were US Food and Drug Administration approved for the treatment of patients with severe eosinophilic asthma. In a clinical trial the novel therapeutic inhaled GATA3 mRNA-specific DNAzyme attenuated early- and late-phase allergic responses to inhaled allergen. These current findings are significant steps toward addressing unmet needs in asthma prevention, severity modification, disparities, and lifespan outcomes.
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Affiliation(s)
- Andrew H Liu
- Breathing Institute and Pulmonary Medicine Section, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo.
| | - William C Anderson
- Allergy & Immunology Section, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
| | - Cullen M Dutmer
- Allergy & Immunology Section, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
| | - Daniel A Searing
- Allergy & Immunology Section, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
| | - Stanley J Szefler
- Breathing Institute and Pulmonary Medicine Section, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
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Aranda CS, Wandalsen GF, Dela Bianca AC, Moraes L, Lamenha Medeiros M, Mallol J, Solé D. Wheezing and the first thousand days of life. Pediatr Allergy Immunol 2017; 28:397-400. [PMID: 28235137 DOI: 10.1111/pai.12710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Ana Caroline Dela Bianca
- Federal University of São Paulo, São Paulo, Brazil.,Federal University of Pernambuco, Recife, Brazil
| | | | | | | | - Dirceu Solé
- Federal University of São Paulo, São Paulo, Brazil
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48
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Muehling LM, Lawrence MG, Woodfolk JA. Pathogenic CD4 + T cells in patients with asthma. J Allergy Clin Immunol 2017; 140:1523-1540. [PMID: 28442213 DOI: 10.1016/j.jaci.2017.02.025] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 02/07/2017] [Accepted: 02/20/2017] [Indexed: 02/08/2023]
Abstract
Asthma encompasses a variety of clinical phenotypes that involve distinct T cell-driven inflammatory processes. Improved understanding of human T-cell biology and the influence of innate cytokines on T-cell responses at the epithelial barrier has led to new asthma paradigms. This review captures recent knowledge on pathogenic CD4+ T cells in asthmatic patients by drawing on observations in mouse models and human disease. In patients with allergic asthma, TH2 cells promote IgE-mediated sensitization, airway hyperreactivity, and eosinophilia. Here we discuss recent discoveries in the myriad molecular pathways that govern the induction of TH2 differentiation and the critical role of GATA-3 in this process. We elaborate on how cross-talk between epithelial cells, dendritic cells, and innate lymphoid cells translates to T-cell outcomes, with an emphasis on the actions of thymic stromal lymphopoietin, IL-25, and IL-33 at the epithelial barrier. New concepts on how T-cell skewing and epitope specificity are shaped by multiple environmental cues integrated by dendritic cell "hubs" are discussed. We also describe advances in understanding the origins of atypical TH2 cells in asthmatic patients, the role of TH1 cells and other non-TH2 types in asthmatic patients, and the features of T-cell pathogenicity at the single-cell level. Progress in technologies that enable highly multiplexed profiling of markers within a single cell promise to overcome barriers to T-cell discovery in human asthmatic patients that could transform our understanding of disease. These developments, along with novel T cell-based therapies, position us to expand the assortment of molecular targets that could facilitate personalized treatments.
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Affiliation(s)
- Lyndsey M Muehling
- Allergy Division, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - Monica G Lawrence
- Allergy Division, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - Judith A Woodfolk
- Allergy Division, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va.
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49
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Ciprandi G, Tosca MA, Silvestri M, Ricciardolo FLM. Inflammatory biomarkers for asthma endotyping and consequent personalized therapy. Expert Rev Clin Immunol 2017; 13:715-721. [PMID: 28347164 DOI: 10.1080/1744666x.2017.1313117] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION We argue that asthma be considered a syndrome caused by multiple inflammatory pathogenic processes. Bronchial hyperresponsiveness, reversible airflow limitation, and chronic airway inflammation characterize asthma pathophysiology. Personalized Medicine, i.e. a tailored management approach, is appropriate for asthma management and is based on the identification of discrete phenotypes and endotypes. Biomarkers can help define phenotypes and endotypes. Several biomarkers have been described in asthma, but most of them are not commonly available or still need external validation. Areas covered: This review presents useful pragmatic biomarkers available in daily clinical practice for assessing airway inflammation in asthmatic patients. Expert commentary: Eosinophil counts and serum allergen-specific IgE assessments are the most reliable biomarkers. Lung function, mainly concerning FEF25-75, and nasal cytology may be envisaged as ancillary biomarkers in asthma management. In conclusion, biomarkers have a clinical relevance in asthma in identifying asthma endotypes to direct personalized therapy.
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Affiliation(s)
- Giorgio Ciprandi
- a Respiratory Allergy, Department of Medicine , IRCCS - Azienda Ospedaliera Universitaria San Martino-IST , Genoa , Italy
| | - Maria Angela Tosca
- b Pediatric Pneumology and Allergy Unit and Cystic Fibrosis Center , IRCCS Istituto Giannina Gaslini , Genoa , Italy
| | - Michela Silvestri
- b Pediatric Pneumology and Allergy Unit and Cystic Fibrosis Center , IRCCS Istituto Giannina Gaslini , Genoa , Italy
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50
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Szymanski KM, Whittam B, Misseri R, Chan KH, Flack CK, Kaefer M, Rink RC, Cain MP. A case of base rate bias, or are adolescents at a higher risk of developing complications after catheterizable urinary channel surgery? J Pediatr Urol 2017; 13:184.e1-184.e6. [PMID: 28159526 DOI: 10.1016/j.jpurol.2016.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 12/05/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Adolescents are considered to be at high risk of developing complications after lower genitourinary tract reconstruction. This perception may be due to base rate bias, where clinicians favor specific information (adolescents with complications), while ignoring more general information (number of total adolescents being followed). The goal of this study was to assess whether age was a true risk factor for subfascial and stomal revisions after continent catheterizable urinary (CCU) channel procedures. MATERIALS AND METHODS Consecutive patients aged <21 years and who underwent appendicovesicostomy and Monti surgery at the present institution were retrospectively reviewed; demographic and surgical data were collected. Time to subfascial or stomal revision was stratified by age at initial surgery (child: <8, preteen: 8-12, adolescent: 13-17, adult: ≥18 years old) and analyzed with Cox proportional-hazards regression. Secondary analyses included: different age categories at initial surgery (<8, 8-11, 12-15, 16-19, ≥20 years), analyzing age as a continuous and a time-varying covariate. RESULTS Of the 510 patients with CCU channels (median age at surgery: 7.9 years), 63 (12.4%) had subfascial and 53 (10.4%) had stomal revision (median follow-up: 6.8 years). Median age at subfascial and stomal revision was 11.3 and 10.3 years, respectively. Preteens contributed 33.0% and adolescents contributed 29.3% of the total follow-up time (3263.9 person-years). Over 80% of revisions occurred within 5 years of surgery, regardless of age at initial surgery (P ≥ 0.57) (Summary table). On multivariate analysis, age at initial surgery was not associated with undergoing subfascial (P ≥ 0.62) or stomal revisions (P ≥ 0.69). Montis were 2.1 times more likely than appendicovesicostomies to undergo a subfascial revision (P = 0.03). No other variables were associated with the risk of subfascial or stomal revision (P ≥ 0.11). Secondary analyses provided similar results. DISCUSSION Since the median age at surgery was 8 years old and most complications occurred within the first 5 years of follow-up, it is not surprising that most revisions occurred in 8-13 year olds. Pediatric urologists appear to base their impression of adolescents being "high risk" on specific information (adolescents having complications), while subconsciously ignoring more general information (adolescents represent a large proportion of patients in follow-up). This study had several limitations: channel complications treated non-surgically (e.g. prolonged catheterization) were not included. The findings may not be generalizable to other genitourinary reconstructive procedures or clinical settings. CONCLUSIONS While complications were twice as high in Monti channels than appendicovesicostomies, no single age group was at increased risk. The impression that adolescents are a high-risk group appears to represent a base rate bias.
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Affiliation(s)
- K M Szymanski
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, 705 Riley Hospital Dr., Suite 4230, Indianapolis, IN 46202, USA.
| | - B Whittam
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, 705 Riley Hospital Dr., Suite 4230, Indianapolis, IN 46202, USA
| | - R Misseri
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, 705 Riley Hospital Dr., Suite 4230, Indianapolis, IN 46202, USA
| | - K H Chan
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, 705 Riley Hospital Dr., Suite 4230, Indianapolis, IN 46202, USA
| | - C K Flack
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, 705 Riley Hospital Dr., Suite 4230, Indianapolis, IN 46202, USA
| | - M Kaefer
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, 705 Riley Hospital Dr., Suite 4230, Indianapolis, IN 46202, USA
| | - R C Rink
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, 705 Riley Hospital Dr., Suite 4230, Indianapolis, IN 46202, USA
| | - M P Cain
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, 705 Riley Hospital Dr., Suite 4230, Indianapolis, IN 46202, USA
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