Community-acquired respiratory viruses after lung transplantation: common, sometimes silent, potentially lethal

Integrating asthma care guidelines into primary care electronic medical records: a review focused on Canadian knowledge translation tools

INTRODUCTION

Asthma is one of the most common chronic respiratory diseases globally. Despite national and international asthma care guidelines, gaps persist in primary care. Knowledge translation (KT) electronic tools (eTools) exist aiming to address these gaps, but their impact on practice patterns and patient outcomes is variable. We aimed to conduct a nonsystematic review of the literature for key asthma care gaps and identify limitations and future directions of KT eTools optimised for use in electronic medical records (EMRs).

METHODS

The database OVID Medline was searched (1999-2024) using keywords such as asthma, KT, primary healthcare and EMRs. Primary research articles, systematic reviews and published international/national guidelines were included. Findings were interpreted within the knowledge-to-action framework.

RESULTS

Key asthma care gaps in primary care include under-recognition of suboptimal control, underutilisation of pulmonary function tests, barriers to care delivery, provider attitudes/beliefs, limited access to asthma education and referral to asthma specialists. Various KT eTools have been validated, many with optimisation for use in EMRs. KT eTools within EMRs have been a recent focus, including asthma management systems, decision support algorithms, data standards initiatives and asthma case definition validation for EMRs.

CONCLUSIONS

The knowledge-to-action cycle is a valuable framework for developing and implementing novel KT tools. Future research should integrate end-users into the process of KT tool development to improve the perceived utility of these tools. Additionally, the priorities of primary care physicians should be considered in future KT tool research to improve end-user uptake and overall asthma management practices.

Nebulization versus metered-dose inhaler and spacer in bronchodilator responsiveness testing: a retrospective study

BACKGROUND

The recommended delivery mode for bronchodilators in bronchodilator responsiveness (BDR) testing remains controversial.

OBJECTIVE

To compare the efficacy of salbutamol administration using a nebulizer versus a metered-dose inhaler (MDI) with spacer in BDR testing.

DESIGN

A retrospective study.

METHODS

This study examined the data of patients with chronic obstructive pulmonary disease who completed BDR testing between 1 December 2021 and 30 June 2022, at Xiangya Hospital, Central South University. After administering 400 μg of salbutamol through an MDI with spacer or 2.5 mg using a nebulizer, the changes in forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were analyzed in patients with moderate-to-very severe spirometric abnormalities [pre-bronchodilator FEV1 percentage predicted values (FEV1%pred) ⩽59%]. Significant responsiveness was assessed as >12% and >200 mL improvement in FEV1 and/or FVC or >10% increase in FEV1%pred or FVC percentage predicted values (FVC%pred) from pre- to post-bronchodilator administration.

RESULTS

Of the enrolled 894 patients, 83.2% were male (median age, 63 years). After propensity score matching, 240 pairs of patients were selected. The increment in FEV1 and increased FEV1 relative to the predicted value (ΔFEV1%pred) were significantly higher in patients <65 years and those with severe spirometric abnormalities in the nebulization group than patients in the MDI group (all p < 0.05). Compared with MDI with spacer, patients who used nebulization had a 30 mL greater increase in ΔFEV1 (95% CI: 0.01-0.05, p = 0.004) and a 1.09% greater increase in ΔFEV1%pred (95% CI: 0.303-1.896, p = 0.007) from baseline. According to the > 12% and >200 mL increase criterion, the significant BDR rate with nebulization was 1.67 times higher than that with an MDI with spacer (OR = 1.67, 95% CI: 1.13-2.47, p = 0.009).

CONCLUSION

Salbutamol delivered using a nebulizer may be preferable to an MDI with spacer in certain circumstances. Nebulization has the potential to increase responsiveness to salbutamol in BDR testing.

The comparison between children and adolescents with asthma provided by the real-world "ControL'Asma" study

OBJECTIVE

Because asthma is a disease that changes over time, the Italian Society of Pediatric Allergy and Immunology launched a nationwide study on asthma control (the ControL'Asma study). The intent was to test the hypothesis that children with asthma could present a different pattern compared to adolescents. In the study, we compared children with adolescents in a real-world setting by analyzing the asthma control grade and other asthma-related parameters.

METHODS

This cross-sectional real-world study included 471 asthmatic children (

RESULTS

There was no difference between the age groups in asthma control as determined by both GINA criteria and the cACT/ACT questionnaires. However, adolescents with asthma had significantly more frequent rhinitis comorbidity (p = 0.02; OR = 2.07) and allergy (p = 0.012; OR = 3.72) than children. Asthma severity, lung function, and symptom perception were not different between age groups.

CONCLUSIONS

The current study showed that asthma control is not associated with age in young people. Adolescents with asthma did experience rhinitis and allergy more frequently than children. These findings reflect the progressive nature of the allergic phenotype in young patients.

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Key Words

• Asthma
• VAS
• adolescents
• allergy
• asthma control
• children
• lung function
• respiratory symptoms
• rhinitis

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MESH Headings

• Asthma/diagnosis
• Cross-Sectional Studies
• Female
• Humans
• Male
• Rhinitis
• Surveys and Questionnaires
• Visual Analog Scale

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Affiliation(s)

Maria Angela Tosca Allergy Center, Department of Pediatrics, Istituto Giannina Gaslini, Genoa, Italy
Angela Pistorio Epidemiology, Biostatistics and Committe, Department of Direction, Istituto Giannina Gaslini, Genoa, Italy
Michela Silvestri Allergy Center, Department of Pediatrics, Istituto Giannina Gaslini, Genoa, Italy
Gian Luigi Marseglia Pediatrics Clinic, Pediatrics Department, Policlinico San Matteo, University of Pavia, Pavia, Italy
Giorgio Ciprandi Allergy Clinic, Department of Outpatients, Casa di Cura Villa Montallegro, Genoa, Italy

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Genome-wide association study of asthma exacerbations despite inhaled corticosteroid use

RATIONALE

Substantial variability in response to asthma treatment with inhaled corticosteroids (ICS) has been described among individuals and populations, suggesting the contribution of genetic factors. Nonetheless, only a few genes have been identified to date. We aimed to identify genetic variants associated with asthma exacerbations despite ICS use in European children and young adults and to validate the findings in non-Europeans. Moreover, we explored whether a gene-set enrichment analysis could suggest potential novel asthma therapies.

METHODS

A genome-wide association study (GWAS) of asthma exacerbations was tested in 2681 children of European descent treated with ICS from eight studies. Suggestive association signals were followed up for replication in 538 European asthma patients. Further evaluation was performed in 1773 non-Europeans. Variants revealed by published GWAS were assessed for replication. Additionally, gene-set enrichment analysis focused on drugs was performed.

RESULTS

10 independent variants were associated with asthma exacerbations despite ICS treatment in the discovery phase (p≤5×10-6). Of those, one variant at the CACNA2D3-WNT5A locus was nominally replicated in Europeans (rs67026078; p=0.010), but this was not validated in non-European populations. Five other genes associated with ICS response in previous studies were replicated. Additionally, an enrichment of associations in genes regulated by trichostatin A treatment was found.

CONCLUSIONS

The intergenic region of CACNA2D3 and WNT5A was revealed as a novel locus for asthma exacerbations despite ICS treatment in European populations. Genes associated were related to trichostatin A, suggesting that this drug could regulate the molecular mechanisms involved in treatment response.

Effect of Nebulized Magnesium vs Placebo Added to Albuterol on Hospitalization Among Children With Refractory Acute Asthma Treated in the Emergency Department: A Randomized Clinical Trial

IMPORTANCE

While intravenous magnesium decreases hospitalizations in refractory pediatric acute asthma, it is variably used because of invasiveness and safety concerns. The benefit of nebulized magnesium to prevent hospitalization is unknown.

OBJECTIVE

To evaluate the effectiveness of nebulized magnesium in children with acute asthma remaining in moderate or severe respiratory distress after initial therapy.

DESIGN, SETTING, AND PARTICIPANTS

A randomized double-blind parallel-group clinical trial from September 26, 2011, to November 19, 2019, in 7 tertiary-care pediatric emergency departments in Canada. The participants were otherwise healthy children aged 2 to 17 years with moderate to severe asthma defined by a Pediatric Respiratory Assessment Measure (PRAM) score of 5 or greater (on a 12-point scale) after a 1-hour treatment with an oral corticosteroid and 3 inhaled albuterol and ipratropium treatments. Of 5846 screened patients, 4332 were excluded for criteria, 273 declined participation, 423 otherwise excluded, 818 randomized, and 816 analyzed.

INTERVENTIONS

Participants were randomized to 3 nebulized albuterol treatments with either magnesium sulfate (n = 410) or 5.5% saline placebo (n = 408).

MAIN OUTCOMES AND MEASURES

The primary outcome was hospitalization for asthma within 24 hours. Secondary outcomes included PRAM score; respiratory rate; oxygen saturation at 60, 120, 180, and 240 minutes; blood pressure at 20, 40, 60, 120, 180, and 240 minutes; and albuterol treatments within 240 minutes.

RESULTS

Among 818 randomized patients (median age, 5 years; 63% males), 816 completed the trial (409 received magnesium; 407, placebo). A total of 178 of the 409 children who received magnesium (43.5%) were hospitalized vs 194 of the 407 who received placebo (47.7%) (difference, -4.2%; absolute risk difference 95% [exact] CI, -11% to 2.8%]; P = .26). There were no significant between-group differences in changes from baseline to 240 minutes in PRAM score (difference of changes, 0.14 points [95% CI, -0.23 to 0.50]; P = .46); respiratory rate (0.17 breaths/min [95% CI, -1.32 to 1.67]; P = .82); oxygen saturation (-0.04% [95% CI, -0.53% to 0.46%]; P = .88); systolic blood pressure (0.78 mm Hg [95% CI, -1.48 to 3.03]; P = .50); or mean number of additional albuterol treatments (magnesium: 1.49, placebo: 1.59; risk ratio, 0.94 [95% CI, 0.79 to 1.11]; P = .47). Nausea/vomiting or sore throat/nose occurred in 17 of the 409 children who received magnesium (4%) and 5 of the 407 who received placebo (1%).

CONCLUSIONS AND RELEVANCE

Among children with refractory acute asthma in the emergency department, nebulized magnesium with albuterol, compared with placebo with albuterol, did not significantly decrease the hospitalization rate for asthma within 24 hours. The findings do not support use of nebulized magnesium with albuterol among children with refractory acute asthma.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01429415.

Personalised exhaled nitric oxygen fraction (F ENO)-driven asthma management in primary care: a F ENO subgroup analysis of the ACCURATE trial

Background

The aim of this study was to identify patients who benefit most from exhaled nitric oxide fraction (F_ENO)-driven asthma management in primary care, based on prespecified subgroups with different levels of F_ENO.

Methods

We used data from 179 adults with asthma from a 12-month primary care randomised controlled trial with 3-monthly assessments of F_ENO, asthma control, medication usage, costs of medication, severe asthma exacerbations and quality of life. In the original study, patients were randomised to either a symptom-driven treatment strategy (controlled asthma (Ca) strategy) or a F_ENO+symptom-driven strategy (FCa). In both groups, patients were categorised by their baseline level of F_ENO as low (<25 ppb), intermediate (25–50 ppb) and high (>50 ppb). At 12 months, we compared, for each prespecified F_ENO subgroup, asthma control, asthma-related quality of life, medication usage, and costs of medication between the Ca and FCa strategy.

Results

We found a difference between the Ca and FCa strategy for the mean dosage of beclomethasone strategy of 223 µg (95% CI 6–439), p=0.04) and for the total costs of asthma medication a mean reduction of US$159 (95% CI US$33–285), p=0.03) in patients with a low baseline F_ENO level. No differences were found for asthma control, severe asthma exacerbations and asthma-related quality of life in patients with a low baseline F_ENO level. Furthermore, in patients with intermediate or high level of F_ENO, no differences were found.

Conclusions

In primary care, F_ENO-driven asthma management is effective in patients with a low F_ENO level, for whom it is possible to down-titrate medication, while preserving asthma control and quality of life.

In primary care, F_ENO-driven asthma management is effective in patients with a low F_ENO, for whom it is possible to down-titrate medication while preserving asthma control and quality of lifehttps://bit.ly/2wC25N7d

Community-acquired Respiratory Viruses Are a Risk Factor for Chronic Lung Allograft Dysfunction

Background

The relationship between community-acquired respiratory viruses (CARVs) and chronic lung allograft dysfunction (CLAD) in lung transplant recipients is still controversial.

Methods

We performed a prospective cohort study (2009–2014) in all consecutive adult patients (≥18 years) undergoing lung transplantation in the Hospital Universitari Vall d’Hebron (Barcelona, Spain). We systematically collected nasopharyngeal swabs from asymptomatic patients during seasonal changes, from patients with upper respiratory tract infectious disease, lower respiratory tract infectious disease (LRTID), or acute rejection. Nasopharyngeal swabs were analyzed by multiplex polymerase chain reaction. Primary outcome was to evaluate the potential association of CARVs and development of CLAD. Time-dependent Cox regression models were performed to identify the independent risk factors for CLAD.

Results

Overall, 98 patients (67 bilateral lung transplant recipients; 63.3% male; mean age, 49.9 years) were included. Mean postoperative follow-up was 3.4 years (interquartile range [IQR], 2.5–4.0 years). Thirty-eight lung transplant recipients (38.8%) developed CLAD, in a median time of 20.4 months (IQR, 12–30.4 months). In time-controlled multivariate analysis, CARV-LRTID (hazard ratio [HR], 3.00 [95% confidence interval {CI}, 1.52–5.91]; P = .002), acute rejection (HR, 2.97 [95% CI, 1.51–5.83]; P = .002), and cytomegalovirus pneumonitis (HR, 3.76 [95% CI, 1.23–11.49]; P = .02) were independent risk factors associated with developing CLAD.

Conclusions

Lung transplant recipients with CARVs in the lower respiratory tract are at increased risk to develop CLAD.

Effect of Exposure to Cats and Dogs on the Risk of Asthma and Allergic Rhinitis: A Systematic Review and Meta-analysis

BACKGROUND

Controversies persist regarding whether exposure to cat or dog increases the risk of asthma and allergic rhinitis.

OBJECTIVE

This meta-analysis aimed to assess the associations between exposure to cats or dogs and the development of asthma and allergic rhinitis.

METHODS

A systematic review was performed to identify case-control and cohort studies before May 2019, evaluating the association between exposure to cats and dogs and the risk of asthma and rhinitis. The risk of bias was assessed using the Newcastle-Ottawa Scale. The odds ratios (ORs) and risk ratios (RRs) were pooled for case-control and cohort studies, respectively. Subgroup analyses were performed on prespecified study-level characteristics.

RESULTS

The meta-analysis of 34 cohort studies showed a protective role of exposure to cats [RR: 0.88, 95% confidence interval (CI): 0.77-0.99] or dogs (RR: 0.85, 95% CI: 0.73-0.97) in the development of asthma. The subgroup analysis of birth cohort (RR: 0.74, 95% CI: 0.56-0.93) and children population (RR: 0.83, 95% CI: 0.70-0.96) also suggested a favorable role of exposure to dogs in the development of asthma. Pooled evidence from 13 case-control studies indicated no significant impact of cats (OR: 1.66, 95% CI: 0.39-2.94) and dogs (OR: 1.22, 95% CI: 0.92-1.52) on the development of asthma. A pooled analysis of five cohort studies showed a favorable effect of exposure to cats (RR: 0.60, 95% CI: 0.33-0.86) or dogs (RR: 0.68, 95% CI 0.44-0.90) on the development of allergic rhinitis.

CONCLUSION

The findings indicated a protective effect of exposure to cats and dogs, especially ownership, on the development of asthma and allergic rhinitis.

YKL-40 mediates airway remodeling in asthma via activating FAK and MAPK signaling pathway

YKL-40 is a chitinase-like protein which was significantly elevated in asthma patients and related closely to asthma severity and airway remodeling. Airway remodeling in asthma involves complicated physical and pathological processes, including increased airway smooth muscle mass due to proliferation, migration of airway smooth muscle cells, epithelial-mesenchymal transition (EMT) and sub-epithelial fibrosis. However, the precise effect and underlying mechanism of YKL-40 in this pathological alteration remained unelucidated. In this study, we demonstrated that YKL-40 could promote asthma airway remodeling by increasing airway smooth muscle mass, inducing EMT and sub-epithelial fibrosis. Furthermore, we identified that FAK and MAPK signaling pathways are activated in the process. Inhibiting FAK or MAPK pathway could significantly ameliorate airway remodeling induced by excessive secretion of YKL-40 in vitro. and in vivo. In conclusion, this study shed light upon the effects of YKL-40 in asthma airway remodeling and provided potential novel targets in asthma patients with high YKL-40 level.

Assessment of fitness for recreational scuba diving in candidates with asthma: a pilot study

BACKGROUND

Asthma may be regarded as a contraindication to scuba diving.

PURPOSE

A clinical algorithm to assess fitness to dive among individuals with asthma was developed and tested prospectively in clinical practice.

STUDY DESIGN

Cohort study.

METHODS

All patients with possible asthma referred to Hvidovre Hospital, Denmark, for assessment of fitness to dive over a 5-year period (2013-2017) were included. Fitness to dive was assessed by case history, spirometry and mannitol challenge test. All patients with ≥10% decline in forced expiratory volume in 1 s (FEV1) (at any point during the challenge test) were offered step-up asthma therapy and rechallenge after at least 3 months. Patients with <10% decline in FEV1 after administration of a maximum dose of mannitol at the latest challenge were classified as having no medical contraindications to scuba diving.

RESULTS

The study cohort comprised 41 patients (24 men; mean age 33 years), of whom 71% and 63% of men and women, respectively, were treated with rescue bronchodilator and inhaled corticosteroid. After the first mannitol challenge test, 21 patients were classified as having no medical contraindications to scuba diving, of whom 16 were currently prescribed asthma medication. After step-up asthma therapy and rechallenge test, an additional seven patients were classified as having no medical contraindications to scuba diving. Overall, using this clinical algorithm, 28 (68%) of the referred patients were finally assessed as having no medical contraindications to scuba diving.

CONCLUSION

Using a clinical algorithm with mannitol challenge to assess fitness to dive among patients with possible asthma and allowing a rechallenge test after step-up asthma therapy increased the proportion of individuals classified as having no medical contraindications to scuba diving. However, as this algorithm has so far not been evaluated against actual scuba diving safety, further studies are clearly needed before it can be implemented with confidence for use in clinical practice.

CLINICAL RELEVANCE

An algorithm to assess fitness for scuba diving among individuals with possible asthma using bronchial challenge test, with the option of step-up asthma therapy and rechallenge for reassessment, has been developed for clinical use.

A Novel Oral Glutarimide Derivative XC8 Suppresses Sephadex-Induced Lung Inflammation in Rats and Ovalbumin-induced Acute and Chronic Asthma in Guinea Pigs

BACKGROUND

Corticosteroids are the preferred option to treat asthma, however, they possess serious side effects and are inefficient in 10% of patients. Thus, new therapeutic approaches for asthma treatment are required.

OBJECTIVE

To study the efficacy of a novel glutarimide derivative XC8 in a Sephadex-induced lung inflammation in rats as well as in acute and chronic ovalbumin-induced allergic asthma in guinea pigs.

METHOD

Rats were treated with 0.18-18 mg/kg of XC8 intragastrically 4 times (24 h and 1 h prior to and 24 h and 45 h after endotracheal administration of Sephadex). The number of inflammatory cells in bronchoalveaolar lavages (BAL) was determined. Guinea pigs were treated with 0.045 -1.4 mg/kg (acute asthma) or with 1.4 and 7.0 mg/kg of XC8 (chronic asthma) intragastrically following the sensitization with ovalbumin and during aerosol challenge. Lung inflammation, numbers of eosinophils (BAL and lung tissue), goblet cells, degranulating mast cells and specific airway resistance (sRAW) were determined. The comparator steroid drug budesonide (0.5 mg/kg for rats and 0.16 mg/kg for guinea pigs) was administered by inhalation.

RESULTS

XC8 reduced influx of eosinophils into BAL in Sephadex-induced lung inflammation model in rats (by 2.6-6.4 times). Treatment of acute asthma in guinea pigs significantly reduced eosinophils in guinea pigs in BAL (from 55% to 30%-39% of the total cell count) and goblet cells in lung tissue. In a model of acute and chronic asthma, XC8 reduced significantly the number of eosinophils and degranulating mast cells in the lung tissue. Treatment with XC8 but not with budesonide decreased the specific airway resistance in acute and chronic asthma model up to the level of naive animals.

CONCLUSION

XC8 induced a profound anti-inflammatory effect by reducing eosinophils in BAL and eosinophils and degranulating mast cell numbers in the airway tissue. The anti-asthmatic effect of XC8 is comparable to that of budesonide. Moreover, in contrast to budesonide, XC8 was capable to reduce goblet cells and airway resistance.

Steroid variability in pediatric inpatient asthmatics: survey on provider preferences of dexamethasone versus prednisone

Objective: Our hospital's pediatric Emergency Department (ED) began using dexamethasone for treating asthma exacerbations after ED studies showed non-inferiority of dexamethasone compared to prednisone. However, providers have not reached consensus on optimal inpatient steroid regimen. This study evaluates provider preference for inpatient steroid treatment.Methods: A survey was distributed to providers who care for inpatient pediatric asthmatics. Respondents answered questions about steroid choice and timing. Data were summarized as percentages; bivariate comparisons were analyzed with Pearson's chi-squared test.Results: Ninety-two providers completed the survey (60% response rate). When patients received dexamethasone in the ED, subsequent inpatient management was variable: 44% continued dexamethasone, 14% switched to prednisone, 2% said no additional steroids, and 40% said it depended on the scenario. Hospitalists were more likely to continue dexamethasone than pulmonologists (61% and 15%, respectively; p < .001). Factors that influenced providers to switch to prednisone in the inpatient setting included severity of exacerbation (73%) and asthma history (47%). Fifty-one percent felt uncomfortable using dexamethasone because of "minimal data to support [its] use inpatient." In case-based questions, 28% selected dexamethasone dosing intervals outside the recommended range. Thirteen percent reported experiencing errors in clinical practice.Conclusions: Use of dexamethasone in the ED for asthma exacerbations has led to uncertainty in inpatient steroid prescribing practices. Providers often revert to prednisone, especially in severe asthma exacerbations, possibly due to experience with prednisone and limited research on dexamethasone in the inpatient setting. Further research comparing the effectiveness of dexamethasone to prednisone in inpatient asthmatic children with various severities of illness is needed.

Salbutamol and ipratropium by inhaler is superior to nebulizer in children with severe acute asthma exacerbation: Randomized clinical trial

INTRODUCTION

In moderate-severe asthma exacerbation, salbutamol by inhaler (MDI) is superior to salbutamol delivered by nebulizer (NEB); however, to our knowledge, no studies in children with exclusively severe exacerbations were performed.

OBJECTIVE

To compare the efficacy of salbutamol and ipratropium bromide by MDI versus by NEB in severe asthma exacerbations.

METHODS

We performed a clinical trial enrolling 103 children (2-14 years of age) with severe asthma exacerbations (defined by the Pulmonary Score ≥ 7) seen at the emergency room in Asuncion, Paraguay. One group received salbutamol and ipratropium (two puff every 10 min for 2 h and then every 30 min for 2 h more) by MDI with a valved-holding chamber and mask along with oxygen by a cannula separately (MDI-SIB); and the other received nebulization with oxygen (NEB-SIB) of salbutamol and ipratropium (1 every 20 min for 2 h and then every 30 min for 2 h more). Primary outcome was the rate of hospitalization (Pulmonary Score ≥ 7) after 4 h and secondary outcome was oxygen saturation.

RESULTS

Fifty two children received MDI-SIB and 51 NEB-SIB. After the 4th hour, children on MDI-SIB had significantly (P = 0.003) lower rate of hospital admission than on NEB-SIB (5.8% vs 27.5%, RR: 0.21 [0.06-0.69], respectively). Similarly, a significant improved clinical score after 60 min and increase in oxygen saturation after 90 min of treatment was observed in MDI-SIB versus NEB-SIB group (4.46 ± 0.7 vs 5.76 ± 0.65, P < 0.00001; and 90.5 ± 1.7 vs 88.43 1 ± 1, P < 0.00001, respectively).

CONCLUSION

Even in severe asthma exacerbations administration of salbutamol and ipratropium by MDI with valved-holding chamber and mask along with oxygen by a cannula separately was more effective than by a nebulizer.

Treatment and outcome of adult patients with acute asthma in emergency departments in Australasia, South East Asia and Europe: Are guidelines followed? AANZDEM/EuroDEM study

OBJECTIVE

Asthma exacerbations are common presentations to ED. Key guideline recommendations for management include administration of inhaled bronchodilators, systemic corticosteroids and titrated oxygen therapy. Our aim was to compare management and outcomes between patients treated for asthma in Europe (EUR) and South East Asia/Australasia (SEA) and compliance with international guidelines.

METHODS

In each region, prospective, interrupted time series studies were performed including adult (age >18 years) patients presenting to ED with the main complaint of dyspnoea during three 72 h periods. This was a planned sub-study that included those with an ED primary diagnosis of asthma. Data was collected on demographics, clinical features, treatment in ED, diagnosis, disposition and in-hospital outcome. The results of interest were differences in treatment and outcome between EUR and SEA cohorts.

RESULTS

Five hundred and eighty-four patients were identified from 112 EDs (66 EUR and 46 SEA). The cohorts had similar demographics and co-morbidity patterns, with 89% of the cohort having a previous diagnosis of asthma. There were no significant differences in treatment between EUR and SEA patients - inhaled beta-agonists were administered in 86% of cases, systemic corticosteroids in 66%, oxygen therapy in 44% and antibiotics in 20%. Two thirds of patients were discharged home from the ED.

CONCLUSION

The data suggests that compliance with guideline-recommended therapy in both regions, particularly corticosteroid administration, is sub-optimal. It also suggests over-use of antibiotics.

Adherence to treatment in allergic respiratory diseases

Introduction: Asthma and allergic rhinitis (AR) are chronic conditions in which management needs adherence to prescribed drugs. Despite the benefits of regular maintenance of asthma and AR therapy, low adherence is a frequent issue in clinical practice. Areas covered: The aim of this review is to provide a targeted analysis of the more recent literature on adherence in asthma and AR, focused on the following areas: adherence extent, barriers and consequences, effects of educational interventions and use of new technologies to improve the level of adherence. Expert commentary: Despite the extent, reasons and effects of this problem being well known, non-adherence in asthma and allergic AR remains worryingly high. Poor adherence leads to unsatisfactory health outcomes, with a negative impact on patients and society. Recent literature suggests that successful programs to improve adherence should include a combination of strategies. The new technologies represent a promising tool to improve adherence.

An evaluation of fevipiprant for the treatment of asthma: a promising new therapy?

INTRODUCTION

Asthma is a heterogeneous disease characterized by chronic airway inflammation that affects more than 230 million people worldwide. Current guidelines recommend an escalating stepwise decision model for the management of asthma. However, disease control continues to be a challenge, particularly in patients with severe asthma. Biologics have proven to be an effective add-on treatment especially in eosinophilic or type 2 airway disease. Comparatively, pre-biologics may represent a successful novel therapy. Fevipiprant (QAW039) is a selective, reversible, antagonist of the prostaglandin D₂ receptor (DP₂). Areas covered: The authors review the mechanism of action of fevipiprant as well as its pharmacokinetics, pharmacodynamics, tolerability, efficacy, and safety. Comparative therapies are also described. A comprehensive literature review was performed using: the PubMed central database, U.S. National Institutes of Health's National Library of Medicine database (NIH/NLM) and the NLM clinical trials database. Expert opinion: Fevipipiprant is a promising prebiologic therapy with convenient dosing, oral administration, and an acceptable safety profile. However, the spectrum of asthmatic patients that may benefit from this therapy is somehow limited to (i.e. moderate to severe eosinophilic asthma). Results from phase III clinical trials are needed to assess whether fevipiprant would lead to a reduction in exacerbation rates and perhaps broaden the target population.

Reasons and outcomes for patients receiving ICS/LABA agents prior to, and one month after, emergency department presentations for acute asthma

Objective: Asthma is a common emergency department (ED) presentation. This study examined factors associated with inhaled corticosteroids/long-acting beta-agonist (ICS/LABA) use; and management and outcomes before and after ED presentation. Methods: Secondary analysis of a prospective cohort study; adults treated for acute asthma in Canadian EDs underwent a structured interview before discharge and were followed-up four weeks later. Patients received oral corticosteroids (OCS) at discharge and, at physician discretion, most received ICS or ICS/LABA inhaled agents. Analyses focused on ICS/LABA vs "other" treatment groups at ED presentation. Results: Of 807 enrolled patients, 33% reported receiving ICS/LABA at ED presentation; 62% were female, median age was 31 years. Factors independently associated with ICS/LABA treatment prior to ED presentation were: having an asthma action plan; using an asthma diary/peak flow meter; influenza immunization; not using the ED as usual site for prescriptions; ever using OCS and currently using ICS. Patients were treated similarly in the ED and at discharge; however, relapse was higher in the ICS/LABA group, even after adjustment. Conclusion: One-third of patients presenting to the ED with acute asthma were already receiving ICS/LABA agents; this treatment was independently associated with preventive measures. While ICS/LABA management improves control of chronic asthma, patients using these agents who develop acute asthma reflect higher severity and increased risk of future relapse.

The influence of dilution on the offline measurement of exhaled nitric oxide

OBJECTIVE

Measurement of fractional exhaled nitric oxide (FeNO) is used to determine the presence and severity of eosinophilic airway inflammation in asthma and other wheezing illnesses. The gold standard of online measurement during a single prolonged exhalation is not suitable for use in young children. The international guidelines for offline measurements recommend collection of exhaled gas in an appropriate reservoir for later analysis in young children. The apparatus required for gas collection, however, creates dead space within the system, which may result in sample dilution and hence inaccuracy. Our objective was to investigate the effect such dilution might have on the accuracy of offline FeNO by comparing the results to online results.

APPROACH

Thirty-five adult subjects without respiratory disease underwent online measurement of FeNO and, thereafter, undertook offline FeNO measurements via exhalation into a collection reservoir using one, five or ten inhalation-exhalation cycles. Fifteen of the subjects also exhaled using the five-breath technique via apparatus with additional dead space. An equation incorporating dead space volume and the number of breaths was used to predict the degree of dilution; the predicted results were compared to the measured results.

MAIN RESULTS

The median (IQR) FeNO from a one-breath technique (22 (15-28) ppb was not significantly different to online values (19 (12-27) ppb, p  =  1.00), but the results from the five-breath technique (11 (4-19) ppb, p  <  0.0001), the ten-breath technique (6 (4-15) ppb, p  <  0.0001) and the additional dead space experiment (6 (3-8) ppb, p  =  0.0006) were significantly lower than online FeNO. Measured values were consistently significantly different to those predicted by the dilution equation, even when incorporating the exact exhaled volume of gas.

SIGNIFICANCE

Offline FeNO results may be inaccurate when subjects are unable to fill the collection reservoir with a single exhalation, thus the technique may not be suitable for preschool children.

Pharmacokinetic drug evaluation of mepolizumab for the treatment of severe asthma associated with persistent eosinophilic inflammation in adults

INTRODUCTION

Mepolizumab is a humanized monoclonal antibody that binds to and inactivates IL-5. It is available as a subcutaneous preparation. The practical application of mepolizumab is as an add-on therapy in the treatment of severe eosinophilic asthma. Areas covered: This article was created from a comprehensive literature search with information taken from meta-analyses, systematic reviews, and clinical trials of adults. The articles that have been selected evaluate the use of mepolizumab and its role in eosinophilic asthma. Expert opinion: Mepolizumab is significantly more effective than placebo in reducing exacerbations and need for systemic corticosteroids in severe eosinophilic asthma. There is a lack of head to head studies comparing mepolizumab to other monoclonal anti-IL-5 inhibitors in severe eosinophilic asthma. Post marketing surveillance revealed risk of anaphylaxis that is below 1%.

Epidemiology and Immediate Indirect Effects of Respiratory Viruses in Lung Transplant Recipients: A 5-Year Prospective Study

The epidemiology of respiratory viruses (RVs) in lung transplant recipients (LTRs) and the relationship of RVs to lung function, acute rejection (AR) and opportunistic infections in these patients are not well known. We performed a prospective cohort study (2009-2014) by collecting nasopharyngeal swabs (NPSs) from asymptomatic LTRs during seasonal changes and from LTRs with upper respiratory tract infectious disease (URTID), lower respiratory tract infectious disease (LRTID) and AR. NPSs were analyzed by multiplex polymerase chain reaction. Overall, 1094 NPSs were collected from 98 patients with a 23.6% positivity rate and mean follow-up of 3.4 years (interquartile range 2.5-4.0 years). Approximately half of URTIDs (47 of 97, 48.5%) and tracheobronchitis cases (22 of 56, 39.3%) were caused by picornavirus, whereas pneumonia was caused mainly by paramyxovirus (four of nine, 44.4%) and influenza (two of nine, 22.2%). In LTRs with LRTID, lung function changed significantly at 1 mo (p = 0.03) and 3 mo (p = 0.04). In a nested case-control analysis, AR was associated with RVs (hazard ratio [HR] 6.54), Pseudomonas aeruginosa was associated with LRTID (HR 8.54), and cytomegalovirus (CMV) replication or disease was associated with URTID (HR 2.53) in the previous 3 mo. There was no association between RVs and Aspergillus spp. colonization or infection (HR 0.71). In conclusion, we documented a high incidence of RV infections in LTRs. LRTID produced significant lung function abnormalities. Associations were observed between AR and RVs, between P. aeruginosa colonization or infection and LRTID, and between CMV replication or disease and URTID.

A CEACAM6-High Airway Neutrophil Phenotype and CEACAM6-High Epithelial Cells Are Features of Severe Asthma

Severe asthma represents a major unmet clinical need; understanding the pathophysiology is essential for the development of new therapies. Using microarray analysis, we previously found three immunological clusters in asthma: Th2-high, Th17-high, and Th2/17-low. Although new therapies are emerging for Th2-high disease, identifying molecular pathways in Th2-low disease remains an important goal. Further interrogation of our previously described microarray dataset revealed upregulation of gene expression for carcinoembryonic Ag cell adhesion molecule (CEACAM) family members in the bronchi of patients with severe asthma. Our aim was therefore to explore the distribution and cellular localization of CEACAM6 using immunohistochemistry on bronchial biopsy tissue obtained from patients with mild-to-severe asthma and healthy control subjects. Human bronchial epithelial cells were used to investigate cytokine and corticosteroid in vitro regulation of CEACAM6 gene expression. CEACAM6 protein expression in bronchial biopsies was increased in airway epithelial cells and lamina propria inflammatory cells in severe asthma compared with healthy control subjects. CEACAM6 in the lamina propria was localized to neutrophils predominantly. Neutrophil density in the bronchial mucosa was similar across health and the spectrum of asthma severity, but the percentage of neutrophils expressing CEACAM6 was significantly increased in severe asthma, suggesting the presence of an altered neutrophil phenotype. CEACAM6 gene expression in cultured epithelial cells was upregulated by wounding and neutrophil elastase. In summary, CEACAM6 expression is increased in severe asthma and primarily associated with airway epithelial cells and tissue neutrophils. CEACAM6 may contribute to the pathology of treatment-resistant asthma via neutrophil and airway epithelial cell-dependent pathways.

Targeting patients with asthma for omalizumab therapy: choosing the right patient to get the best value for money

The asthma syndrome has many manifestations, termed phenotypes, that arise by specific cellular and molecular mechanisms, termed endotypes. Understanding an individual's asthma phenotype helps clinicians make rational therapeutic decisions while the understanding of endotypes has led to the development of specific precision medications. Allergic asthma is an example of an asthma phenotype and omalizumab, a monoclonal antibody that neutralizes serum immunoglobulin (Ig)E, is a specific targeted treatment which was developed as a result of an understanding of the endotype of allergic asthma. Omalizumab has been widely used in clinical practice in Europe for over a decade as an add-on therapy to treat patients who have severe refractory allergic asthma. Over this period, many centres have reported their experience with omalizumab as an add-on therapy in patients with severe asthma. These 'real world' clinical effectiveness studies have confirmed the benefits, cost-effectiveness and clinical utility of this medication. Combining the outcomes of both sources of research has yielded important insights that may benefit patients with severe asthma, clinicians who treat them, as well as the funding agencies that reimburse the cost of this medication. The purpose of this review is to describe how to identify and evaluate a patient with asthma for whom treatment with omalizumab may be of clinical and cost-effective benefit. The assessment and investigations used to confirm allergic asthma, the objective assessment of adherence to asthma therapy and the expected benefits of add-on omalizumab treatment are described.

Severe Asthma: Have We Made Progress?

Tremendous efforts have been invested in research to (1) discover risk factors, biomarkers, and clinical characteristics; (2) understand the pathophysiology and treatment response variability in severe asthma; and (3) design new therapies. However, to combat severe asthma, many questions concerning the pathogenesis of severe asthma, including its natural history, genetic and environmental risk factors, and disease mechanisms, must be answered. In this article we highlight some of the major discoveries concerning the pathogenesis of severe asthma and its therapeutic development. We conclude that discoveries on numerous fronts of severe asthma, from disease heterogeneity, features of airway remodeling, cytokine mediators and signaling pathways underlying disease pathogenesis, disease mechanisms, potential biomarkers, to new therapeutic targets, demonstrate that progress has been made in understanding and developing more effective treatments for this difficult-to-treat disease.

Anti-Inflammatory Effects of Ginsenoside Rg3 via NF-κB Pathway in A549 Cells and Human Asthmatic Lung Tissue

Objective. There is limited information of the anti-inflammatory effects of Rg3 on inflamed lung cells and tissues. Therefore, we confirmed the anti-inflammatory mechanism of ginsenoside Rg3 in inflamed human airway epithelial cells (A549) and tissues whether Rg3 regulates nuclear factor kappa B (NF-κB) activity. Methods. To induce the inflammation, IL-1β (10 ng/ml) was treated to A549 cells for 4 h. The effects of Rg3 on NF-κB activity and COX-2 expression were evaluated by western blotting analysis in both IL-1β-induced inflamed A549 cell and human asthmatic airway epithelial tissues. Using multiplex cytokines assay, the secretion levels of NF-κB-mediated cytokines/chemokines were measured. Result. Rg3 showed the significant inhibition of NF-κB activity thereby reduced COX-2 expression was determined in both IL-1β-induced inflamed A549 cell and human asthmatic airway epithelial tissues. In addition, among NF-κB-mediated cytokines, the secretion levels of IL-4, TNF-α, and eotaxin were significantly decreased by Rg3 in asthma tissues. Even though there was no significant difference, IL-6, IL-9, and IL-13 secretion showed a lower tendency compared to saline-treated human asthmatic airway epithelial tissues. Conclusion. The results from this study demonstrate the potential of Rg3 as an anti-inflammatory agent through regulating NF-κB activity and reducing the secretion of NF-κB-mediated cytokines/chemokines.

Azithromycin for Acute Exacerbations of Asthma : The AZALEA Randomized Clinical Trial

IMPORTANCE

Guidelines recommend against antibiotic use to treat asthma attacks. A study with telithromycin reported benefit, but adverse reactions limit its use.

OBJECTIVE

To determine whether azithromycin added to standard care for asthma attacks in adults results in clinical benefit.

DESIGN, SETTING, AND PARTICIPANTS

The Azithromycin Against Placebo in Exacerbations of Asthma (AZALEA) randomized, double-blind, placebo-controlled clinical trial, a United Kingdom-based multicenter study in adults requesting emergency care for acute asthma exacerbations, ran from September 2011 to April 2014. Adults with a history of asthma for more than 6 months were recruited within 48 hours of presentation to medical care with an acute deterioration in asthma control requiring a course of oral and/or systemic corticosteroids.

INTERVENTIONS

Azithromycin 500 mg daily or matched placebo for 3 days.

MAIN OUTCOMES AND MEASURES

The primary outcome was diary card symptom score 10 days after randomization, with a hypothesized treatment effect size of -0.3. Secondary outcomes were diary card symptom score, quality-of-life questionnaires, and lung function changes, all between exacerbation and day 10, and time to a 50% reduction in symptom score.

RESULTS

Of 4582 patients screened at 31 centers, 199 of a planned 380 were randomized within 48 hours of presentation. The major reason for nonrecruitment was receipt of antibiotics (2044 [44.6%] screened patients). Median time from presentation to drug administration was 22 hours (interquartile range, 14-28 hours). Exacerbation characteristics were well balanced across treatment arms and centers. The primary outcome asthma symptom scores were mean (SD), 4.14 (1.38) at exacerbation and 2.09 (1.71) at 10 days for the azithromycin group and 4.18 (1.48) and 2.20 (1.51) for the placebo group, respectively. Using multilevel modeling, there was no significant difference in symptom scores between azithromycin and placebo at day 10 (difference, -0.166; 95% CI, -0.670 to 0.337), nor on any day between exacerbation and day 10. No significant between-group differences were observed in quality-of-life questionnaires or lung function between exacerbation and day 10, or in time to 50% reduction in symptom score.

CONCLUSIONS AND RELEVANCE

In this randomized population, azithromycin treatment resulted in no statistically or clinically significant benefit. For each patient randomized, more than 10 were excluded because they had already received antibiotics.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01444469.

Changing Provider Behavior in the Context of Chronic Disease Management: Focus on Clinical Inertia

Widespread acceptance of evidence-based medicine has led to the proliferation of clinical practice guidelines as the primary mode of communicating current best practices across a range of chronic diseases. Despite overwhelming evidence supporting the benefits of their use, there is a long history of poor uptake by providers. Nonadherence to clinical practice guidelines is referred to as clinical inertia and represents provider failure to initiate or intensify treatment despite a clear indication to do so. Here we review evidence for the ubiquity of clinical inertia across a variety of chronic health conditions, as well as the organizational and system, patient, and provider factors that serve to maintain it. Limitations are highlighted in the emerging literature examining interventions to reduce clinical inertia. An evidence-based framework to address these limitations is proposed that uses behavior change theory and advocates for shared decision making and enhanced guideline development and dissemination.

Asthma prescribing, ethnicity and risk of hospital admission: an analysis of 35,864 linked primary and secondary care records in East London

Inappropriate prescribing in primary care was implicated in nearly half of asthma deaths reviewed in the UK’s recent National Review of Asthma Deaths. Using anonymised EMIS-Web data for 139 ethnically diverse general practices (total population 942,511) extracted from the North and East London Commissioning Support Unit, which holds hospital Secondary Uses Services (SUS)–linked data, we examined the prevalence of over-prescribing of short-acting β₂-agonist inhalers (SABA), under-prescribing of inhaled corticosteroid (ICS) inhalers and solo prescribing of long-acting β₂-agonists (LABA) to assess the risk of hospitalisation for people with asthma for 1 year ending August 2015. In a total asthma population of 35,864, multivariate analyses in adults showed that the risk of admission increased with greater prescription of SABA inhalers above a baseline of 1–3 (4–12 SABA: odds ratio (OR) 1.71; 95% confidence interval (CI) 1.20–2.46, ⩾13 SABA: OR 3.22; 95% CI 2.04–5.07) with increasing British Thoracic Society step (Step 3: OR 2.90; 95% CI 1.79–4.69, Step 4/5: OR 9.42; 95% CI 5.27–16.84), and among Black (OR 2.30; 95% CI 1.64–3.23) and south Asian adult populations (OR 1.83; 95% CI 1.36–2.47). Results in children were similar, but risk of hospitalisation was not related to ethnic group. There is a progressive risk of hospital admission associated with the prescription of more than three SABA inhalers a year. Adults (but not children) from Black and South Asian groups are at an increased risk of admission. Further work is needed to target care for these at-risk groups.

A multidisciplinary team case management approach reduces the burden of frequent asthma admissions

Up to 10% of asthmatics have “difficult asthma”; however, they account for 80% of asthma-related expenditure and run the highest risk of acute severe exacerbations. An estimated 75% of admissions for asthma are avoidable. Guidelines advise that these patients be managed by an experienced specialist multidisciplinary team (MDT). We aimed to assess the impact of a case management strategy delivered via specialist MDTs on acute healthcare utilisation of patients with frequent asthma admissions.

An MDT (consultant, specialist nurse, physiotherapist and psychologist) case management strategy was introduced in 2010 at University Hospital Southampton Foundation Trust (Southampton, UK) to support patients with frequent asthma admissions during admission and then in clinic. To assess efficacy, we systematically searched the hospital database for patients acutely admitted for asthma on two or more occasions in 2010, 2011 and 2012. Data were collected retrospectively covering patient demographics, admission details, asthma severity and comorbidity.

From 2010 to 2012, 84 patients were admitted on two or more occasions per year (80% female, mean body mass index 31 kg·m⁻² and 55% psychological comorbidity). After introducing an MDT approach repeat asthma admissions fell by 33% from 127 in 2010 to 84 in 2012 (p=0.0004). In addition, bed days fell by 52% from 895 in 2010 to 430 in 2010 (p=0.015).

An MDT case management approach significantly reduces hospitalisation in difficult asthma patients with prior frequent admission.

MDT case management approach significantly reduces hospitalisation in asthma patients with prior frequent admissionhttp://ow.ly/7iOI3016277

Challenges in the pharmacological treatment of geriatric asthma

Asthma in older populations is characterized by frequent comorbid conditions, which increase the risk of side effects and of detrimental interactions between respiratory and non-respiratory drugs. These observations lead to the need to manage asthma in older populations by applying a multidimensional assessment and a multidisciplinary treatment; therefore, we favor the use of the 'geriatric' term to define asthma in the elderly. Geriatric asthma is a complex disease, which may not necessarily imply that it is also complicated, although the two conditions may often coexist. On this basis, the switch from an organ-driven management to the holistic approach may be the key factor to attain optimal control of the disease in this age range. The current review discusses the age-related factors affecting asthma treatment in the oldest individuals, such as the comorbid conditions, and age-related changes of metabolism and excretion that can impair the efficacy and safety of drugs.

Asthma insights from Jordan: cross-sectional observational study

OBJECTIVE

The burden of uncontrolled asthma on patients in Jordan is largely unknown. This study assessed different aspects of asthma clinical features: the level of asthma control, its correlation with quality of life, and possible predictors of asthma control.

METHODS

Face-to-face interviews with asthmatic patients (≥16 years old) in north Jordan from 2013 to 2014 were conducted. Outcomes measures were assessed using the asthma control test (ACT), the mini asthma quality of life questionnaire (mini-AQLQ), and the Generic health-related quality of life (EQ-5D). The relationship between asthma control and quality of life was examined using Spearman's correlation coefficient. Predictors of asthma control were determined using multivariable logistic regression adjusted for confounders.

RESULTS

A total of 255 patients were recruited (mean age 45.16 years, 74.5% female). Approximately one-third of subjects (30.6%; n = 78) had controlled asthma (ACT ≥ 20). A strong correlation between asthma control and both mini-AQLQ and EQ-5D scores was identified (p < 0.001). Subjects who required to step-up treatment (OR = 0.12, 95% CI: 0.02-0.63, p = 0.01) and with acute asthma exacerbation (OR = 0.32, 95% CI: 0.18-0.58, p < 0.001) were independently associated with poor asthma control.

CONCLUSIONS

Most of the recruited patients have not achieved optimal asthma control and was associated with low quality of life. The study highlights that even in low-income countries, a simple assessment tool such as the ACT can be utilized to screen and categorize asthma control. This approach would facilitate a better treatment plan and eventually improve asthma control and quality of life in asthma patients.

Lung Transplantation

The therapeutic options for patients with advanced pulmonary parenchymal or vascular disorders are currently limited. Lung transplantation remains one of the few viable interventions, but on account of the insufficient donor pool only a minority of these patients actually undergo the procedure each year. Following transplantation there are a number of early and late allograft complications such as primary graft dysfunction, allograft rejection, infection, post-transplant lymphoproliferative disorder and late injury that is now classified as chronic lung allograft dysfunction. The pathologist plays an essential role in the diagnosis and classification of these myriad complications. Although the transplant procedures are performed in selected centers patients typically return to their local centers. When complications arise it is often the responsibility of the local pathologist to evaluate specimens. Therefore familiarity with the pathology of lung transplantation is important.

Clinical asthma phenotypes in the real world: opportunities and challenges

Asthma is a common, chronic and heterogeneous syndrome, affecting people of all ages, all races and both sexes. It may range from mild disease with barely noticeable symptoms, to very severe disease with constant symptoms that greatly hinder the life of the patient. Guidelines issued by various medical societies provide guidance on how to diagnose and manage asthmatic patients. It is now increasingly recognised that asthma management must be individualised, tailored not only to the severity of the disease but to the phenotypic characteristics of each patient. The aim of asthma treatment is control of asthma and the prevention of risk of exacerbations and fixed airflow limitation. Asthma control can be easily assessed clinically through simple screening tools such as the use of validated questionnaires and spirometry. The use of inflammatory biomarkers can be an alternative approach that, however, requires more time and resources. Asthma treatment involves the use of controllers, mainly inhaled corticosteroids and long-acting β2-agonists, and relievers, mainly rapid-acting β2-agonists. Controller medications reduce airway inflammation, lead to better symptom control and reduce the risk of future exacerbations. Reliever (rescue) medications alleviate symptoms and prevent exercise-induced bronchoconstriction. Treatment must be based on a "stepwise approach" in order to achieve good control of symptoms and to minimise future risks of exacerbations. That is, less treatment for mild disease, more treatment for severe, uncontrolled disease. Once good asthma control has been achieved and maintained, treatment should be stepped down. In severe asthmatics, phenotypic characterisation becomes more clinically useful and add-on treatment such as anti-immunoglobulin E monoclonal antibodies may be required. Despite our better understanding of asthma, there are still patients who will not respond to treatment and remain symptomatic. Dissemination of guidelines and national plans allowing early diagnosis of asthma as well as access to specialised primary and secondary care for asthmatic patients, personalised treatment and continuity of care may lead to excellence in care and controlled asthma for the majority of patients. Education of the patient in asthma is also very important, as in every chronic disease, as the patients live with the disease every day while they visit a healthcare professional a few times a year. Future planning for new treatments should focus on the needs of such severe asthma patients.

Epigenome-modifying tools in asthma

Asthma is a chronic disease which causes recurrent breathlessness affecting 300 million people worldwide of whom 250,000 die annually. The epigenome is a set of heritable modifications and tags that affect the genome without changing the intrinsic DNA sequence. These marks include DNA methylation, modifications to histone proteins around which DNA is wrapped and expression of noncoding RNA. Alterations in all of these processes have been reported in patients with asthma. In some cases these differences are linked to disease severity and susceptibility and may account for the limited value of genetic studies in asthma. Animal models of asthma suggest that epigenetic modifications and processes are linked to asthma and may be tractable targets for therapeutic intervention.

Immunoglobulin E in irritable bowel syndrome: another target for treatment? A case report and literature review

Irritable bowel syndrome (IBS) is notoriously difficult to treat and this situation is unlikely to change until the pathophysiology is better understood. There is no doubt that IBS is a multifactorial condition but it is likely that the relative contribution of the various factors involved varies from patient to patient. Consequently, in some individuals one mechanism may have such a strong effect that its elimination may lead to a substantial improvement in symptoms. This paper describes a patient with severe asthma and IBS where the administration of an anti-Immunoglobulin E (IgE) monoclonal antibody not only improved her asthma but also resulted in an almost complete resolution of her IBS symptoms. This observation suggests that some form of allergic process, which may be mediated by IgE, might be driving IBS in some patients and there is evidence from the literature that atopy is more common in this condition. Therefore, in patients with IBS and atopy where the response to standard treatment is poor, it may be worth considering targeting the allergic diathesis. Possible approaches include skin testing with food antigens followed by an appropriate exclusion diet or pharmacological mast cell stabilization.

Treatment of severe asthma: entering the era of targeted therapy

INTRODUCTION

It is estimated that 5 - 10% of asthma patients suffer from severe asthma. Severe asthma is associated with increased morbidity and mortality. These patients are not controlled with currently available treatments and therefore additional treatment options are needed. Asthma is a heterogeneous disease, and different asthma patient groups probably have different underlying pathophysiology. Novel therapies with, for example, monoclonal antibodies that target certain immunological pathways have become available. These novel treatments are not effective in all patients but only in certain phenotypes.

AREAS COVERED

This review covers the current evidence and novel developments in treatment with monoclonal antibodies in different asthma phenotypes. This includes monoclonal antibodies against IgE, against interleukin (IL)-5 and antibodies targeting IL-13 pathways. Although there is a certain overlap between patient groups benefiting from these treatments, a more detailed identification of responder profiles for these therapies is needed for personalized therapy.

EXPERT OPINION

In recent years, novel monoclonal antibodies have been developed, which are a promising addition to existing therapy in the treatment of severe asthma with eosinophilic inflammation and Th2-driven disease. We expect that several of the new antibodies will become available for clinical practice. In addition, it must be acknowledged that so far no effective strategies are available for patients with non-eosinophilic asthma and further research and development is necessary for this patient group.

Principal findings of systematic reviews of acute asthma treatment in childhood

OBJECTIVE

The objective of this study is to summarize the principal findings in the literature about acute asthma management in children.

METHODS

Systematic reviews of randomized clinical trials (SRCTs) with or without meta-analysis in children (1-18 years) admitted to the emergency department (ED) were retrieved using five data bases. Methodological quality was determined using the AMSTAR tool.

RESULTS

One hundred and three studies were retrieved. Among those, 28 SRCTs were included: seven SRCTs related to short-acting beta2-agonists (SABA), three to ipratropium bromide (IB), eight to corticosteroids, one to racemic adrenaline, one to leukotriene receptor antagonists (LTRA), four to magnesium sulfate, one to intravenous (IV) SABA, one to IV aminophylline, one to IV ketamine, and one to antibiotics. It was determined that administering SABA by MDI-VHC is superior to using a nebulizer, because it decreases the hospital admission rate, improves the clinical score, results in a shorter time in the ED, and causes fewer adverse effects. Levalbuterol and albuterol were similar. In patients with moderate to severe exacerbations, IB+SABA was superior to SABA, decreasing hospital admission and improving the clinical score. SABA heliox administered by nebulizer decreased exacerbation severity compared to oxygen. Inhaled corticosteroids (ICS), especially administered by nebulizer, showed results similar to oral corticosteroids (OCS) with respect to reducing hospital admission, unscheduled visits, and the requirement of additional systemic corticosteroids. ICS or OCS following ED discharge was similar with regard to relapse. Compared with a placebo, IV magnesium reduced hospital admission and improved lung function.

CONCLUSIONS

SRCTs are useful for guiding decisions in acute asthma treatment.