AIR Louisville: Addressing Asthma With Technology, Crowdsourcing, Cross-Sector Collaboration, And Policy

Clinical translation of nanomedicine with integrated digital medicine and machine learning interventions

Nanomaterials based therapeutics transform the ways of disease prevention, diagnosis and treatment with increasing sophistications in nanotechnology at a breakneck pace, but very few could reach to the clinic due to inconsistencies in preclinical studies followed by regulatory hinderances. To tackle this, integrating the nanomedicine discovery with digital medicine provide technologies as tools of specific biological activity measurement. Hence, overcome the redundancies in nanomedicine discovery by the on-site data acquisition and analytics through integrating intelligent sensors and artificial intelligence (AI) or machine learning (ML). Integrated AI/ML wearable sensors directly gather clinically relevant biochemical information from the subject's body and process data for physicians to make right clinical decision(s) in a time and cost-effective way. This review summarizes insights and recommend the infusion of actionable big data computation enabled sensors in burgeoning field of nanomedicine at academia, research institutes, and pharmaceutical industries, with a potential of clinical translation. Furthermore, many blind spots are present in modern clinically relevant computation, one of which could prevent ML-guided low-cost new nanomedicine development from being successfully translated into the clinic was also discussed.

Remote digital health technologies for improving the care of people with respiratory disorders

Respiratory diseases are a leading cause of morbidity and mortality globally. However, existing systems of care, built around scheduled appointments, are not well designed to support the needs of people with chronic and acute respiratory conditions that can change rapidly and unexpectedly. Home-based and personal digital health technologies (DHTs) allow implementation of new models of care catering to the unique needs of individuals. The high number of respiratory triggers and unique responses to them require a personalised solution for each patient. The real-world, repetitive monitoring capabilities of DHTs enable identification of the normal operating characteristics for each individual and, therefore, recognition of the earliest deviations from that state. However, despite this potential, the number of clinical efficacy studies of DHTs is quite small. Evaluation of clinical effectiveness of DHTs in improving health quality in real-world settings is urgently needed.

Auditing the Audits: A Systematic Review on Different Procedures in Telemedicine

Telemedicine is a process of delivering health care using information and communication technologies. Audit and feedback (A&F) constitute a systematic intervention that is aimed at collecting data, which are subsequently compared with reference standards and then returned to health care operators through feedback meetings. The aim of this review is to analyse different audit procedures on and by mean of telemedicine services and to identify a practice that is more effective than the others. Systematic searches were performed in three databases evaluating studies focusing on clinical audits performed on and by means of telemedicine systems. Twenty-five studies were included in the review. Most of them focused on telecounselling services with an audit and a maximum duration of one year. Recipients of the audit were telemedicine systems and service users (general practitioners, referring doctors, and patients). Data resulting from the audit were inherent to the telemedicine service. The overall data collected concerned the number of teleconsultations, service activity, reasons for referral, response times, follow-up, reasons why treatment was not completed, technical issues, and other information specific to each telemedicine service. Only two of the considered studies dealt with organizational aspects, and of these, only one analysed communicative aspects. The complexity and heterogeneity of the treatments and services provided meant that no index of uniformity could be identified. Certainly, some audits were performed in an overlapping manner in the different studies, and these show that although attention is often paid to workers' opinions, needs, and issues, little interest was shown in communicative/organizational and team dynamics. Given the importance and influence that communication has in teamwork and care settings, an audit protocol that takes into account intra- and extra-team communication processes could be essential to improving the well-being of operators and the quality of the service provided.

Integrative Analysis of Rhythmicity: From Biology to Urban Environments and Sustainability

From biological to socio-technical systems, rhythmic processes are pervasive in our environment. However, methods for their comprehensive analysis are prevalent only in specific fields that limit the transfer of knowledge across scientific disciplines. This hinders interdisciplinary research and integrative analyses of rhythms across different domains and datasets. In this paper, we review recent developments in cross-disciplinary rhythmicity research, with a focus on the importance of rhythmic analyses in urban planning and biomedical research. Furthermore, we describe the current state of the art of (integrative) computational methods for the investigation of rhythmic data. Finally, we discuss the further potential and propose necessary future developments for cross-disciplinary rhythmicity analysis to foster integration of heterogeneous datasets across different domains, as well as guide data-driven decision making beyond the boundaries of traditional intradisciplinary research, especially in the context of sustainable and healthy cities.

Shape Memory Alloy-Based Wearables: A Review, and Conceptual Frameworks on HCI and HRI in Industry 4.0

Ever since its discovery, the applications of Shape Memory Alloys (SMA) can be found across a range of application domains, from structural design to medical technology. This is based upon the unique and inherent characteristics such as thermal Shape Memory Effect (SME) and Superelasticity (or Pseudoelasticity). While thermal SME is used for shape morphing applications wherein temperature change can govern the shape and dimension of the SMA, Superelasticity allows the alloy to withstand a comparatively very high magnitude of loads without undergoing plastic deformation at higher temperatures. These unique properties in wearables have revolutionized the field, and from fabrics to exoskeletons, SMA has found its place in robotics and cobotics. This review article focuses on the most recent research work in the field of SMA-based smart wearables paired with robotic applications for human-robot interaction. The literature is categorized based on SMA property incorporated and on actuator or sensor-based concept. Further, use-cases or conceptual frameworks for SMA fiber in fabric for 'Smart Jacket' and SMA springs in the shoe soles for 'Smart Shoes' are proposed. The conceptual frameworks are built upon existing technologies; however, their utility in a smart factory concept is emphasized, and algorithms to achieve the same are proposed. The integration of the two concepts with the Industrial Internet of Things (IIoT) is discussed, specifically regarding minimizing hazards for the worker/user in Industry 5.0. The article aims to propel a discussion regarding the multi-faceted applications of SMAs in human-robot interaction and Industry 5.0. Furthermore, the challenges and the limitations of the smart alloy and the technological barriers restricting the growth of SMA applications in the field of smart wearables are observed and elaborated.

Technology Basics for Telemedicine: What Practitioners Need to Know

Veterinary medical technology is rapidly evolving and provides exciting opportunities for veterinarians to practice medicine in new ways. This article reviews the basic components of telemedicine technology that practitioners should be aware of.

Perceptions of Environmental Influence and Environmental Information-Seeking Behavior Among People With Asthma and COPD

Environmental exposures and socioeconomic status (SES) are associated with asthma and chronic obstructive pulmonary disease (COPD) morbidity and mortality. Despite efforts to reduce the impact of environmental exposures through regulation and education, knowledge gaps remain. We sought to understand how adults with asthma and COPD perceive and seek information about environmental factors, and how these responses varied by disease or socioeconomic characteristics. Participants with self-reported asthma or COPD enrolled in a digital platform for respiratory disease self-management, consisting of sensors to track medication use and a companion smartphone app, completed an electronic survey exploring perceptions of environmental factors. Using mixed-method analyses, we evaluated differences in responses by disease (asthma vs. COPD), education (≤ vs. > some college), annual household income (< vs. ≥ $50,000), and mean annual residential air pollutant exposure (> vs. ≤80th percentile). Survey responses from 698 participants [500 asthma (72%) and 198 COPD (28%)] were analyzed. A high percentage of participants perceived that environmental factors could influence their symptoms, including: pollen (93% for asthma vs. 86% for COPD), mold (89 vs. 85%), second-hand smoke (89 vs. 83%), and air pollution (84% for both). Participants reported seeking environmental information daily from an average of three sources, preferring mobile apps and television (TV) programs. Significant differences were identified by disease.

Conclusion

Participants with asthma and COPD perceive a relationship between their respiratory symptoms and their environment and regularly seek out environmental information. This information can help inform digital health development for respiratory education and self-management.

Identification of Digital Health Priorities for Palliative Care Research: Modified Delphi Study

BACKGROUND

Developments in digital health have the potential to transform the delivery of health and social care to help citizens manage their health. Currently, there is a lack of consensus about digital health research priorities in palliative care and a lack of theories about how these technologies might improve care outcomes. Therefore, it is important for health care leaders to identify innovations to ensure that an increasingly frail population has appropriate access to palliative care services. Consequently, it is important to articulate research priorities as the first step in determining how finite resources should be allocated to a field saturated with rapidly developing innovation.

OBJECTIVE

The aim of this study is to identify research priority areas for digital health in palliative care.

METHODS

We selected digital health trends, most relevant to palliative care, from a list of emerging trends reported by a leading institute of quantitative futurists. We conducted 2 rounds of the Delphi questionnaire, followed by a consensus meeting and public engagement workshop to establish a final consensus on research priorities for digital technology in palliative care. We used the views of public representatives to gain their perspectives on the agreed priorities.

RESULTS

A total of 103 experts (representing 11 countries) participated in the first Delphi round. Of the 103 experts, 55 (53.3%) participated in the second round. The final consensus meetings were attended by 10.7% (11/103) of the experts. We identified 16 priority areas, which involved many applications of technologies, including care for patients and caregivers, self-management and reporting of diseases, education and training, communication, care coordination, and research methodology. We summarized the priority areas into eight topics: big data, mobile devices, telehealth and telemedicine, virtual reality, artificial intelligence, smart home, biotechnology, and digital legacy.

CONCLUSIONS

The priorities identified in this study represent a wide range of important emerging areas in the fields of digital health, personalized medicine, and data science. Human-centered design and robust governance systems should be considered in future research. It is important that the risks of using these technologies in palliative care are properly addressed to ensure that these tools are used meaningfully, wisely, and safely and do not cause unintentional harm.

Using Telemedicine to Care for the Asthma Patient

Purpose of Review

To review the data supporting the use of telemedicine (TM) and to provide practical guidance for practitioners to optimize the care of their asthmatic patients.

Recent Findings

Previous to the pandemic, TM was little used in various aspects of asthma care. Since the pandemic, TM has been increasingly used in new ways to care for asthma patients at various locations. In addition to direct-to-consumer visits for asthma care, other forms of telehealth visits have been increasing such as facilitated visits, asynchronous, remote patient monitoring, e-consults, and mHealth. Moreover, patient and provider satisfaction with the use of TM has been increasing and is comparable at times with face-to-face visits. In this review, best practices for starting a telemedicine asthma service with patients at home, distant clinic sites, and various other locations, including school-based asthma programs, are reviewed.

Summary

TM is a valuable adjunct to face-to-face visits for asthma care. Following the recommended best practices can strengthen the implementation of a telemedicine asthma program (TMAP) into clinical practice. Providers must be vigilant in keeping current with the various nuances required for asthma telemedicine care in preparation for the post-pandemic environment.

Indacaterol/glycopyrronium/mometasone fixed dose combination for uncontrolled asthma

INTRODUCTION

Asthma symptoms can be relieved through a maintenance treatment combining long-acting β₂-agonist and inhaled corticosteroids (LABA/ICS). However, for patients with inadequately controlled asthma, the LABA/ICS combination might not be sufficient, and clinical guidelines recommend the administration of inhaled long-acting muscarinic antagonists (LAMA) as an add-on therapy to better control asthma and improve lung function. For nearly two decades, the only LAMA to be approved on the market has been tiotropium.

AREAS COVERED

We reviewed recent clinical studies evaluating the safety and efficacy of LABA/LAMA/ICS fixed dose combinations by searching the PubMed database. Molecular mechanisms and clinical data support the use of a once-daily, single-inhaler fixed dose combination of the LABA/LAMA/ICS indacaterol/glycopyrronium/mometasone (IND/GLY/MF), the first therapy combining three agents in a fixed dose approved in Europe for the treatment of uncontrolled asthma.

EXPERT OPINION

IND/GLY/MF was superior to both IND/MF and salmeterol/fluticasone, a well-established LABA/ICS combination improving the lung function in uncontrolled asthma. Moreover, IND/GLY/MF, delivered through the Breezhaler inhaler in a single inhalation, is the first inhaled therapy prescribed alongside a digital companion, a sensor and the Propeller app, allowing for improved treatment adherence, reduced rescue inhaler usage and hospitalizations, increased patient satisfaction and asthma control.

Reevaluating medication adherence in the era of digital health

INTRODUCTION

Medication adherence is a worldwide issue impacting more than half the population. The cost associated with nonadherence is tremendous and has spurred the growth of novel technologies to address this growing problem.

AREAS COVERED

This perspective covers the different digital health medication adherence tools that have come to market in the past decade and their clinical impact. These digital interventions and their applicability to medication adherence across different stakeholders are then evaluated.

EXPERT OPINION

Digital health will play a significant role in creating new pathways to care in the 2020s. However, the current design of medication adherence tools has not demonstrated a clinical impact that will be relevant for the digital health space without a change in redesign factoring in relevant stakeholders' incentives to address adherence issues. A focus on only adherence has not yielded the economic or clinical benefit as expected, which is likely due to a lack of focus on broader drug-related problems (DRPs) that are causative factors beyond adherence alone. As such, adherence tools will see disparate uptake, likely due to condition-specific interventions rather than adherence issues as a whole, and future endeavors will need to address the larger DRP considerations to actualize clinical outcomes.

Identifying impacts of air pollution on subacute asthma symptoms using digital medication sensors

BACKGROUND

Objective tracking of asthma medication use and exposure in real-time and space has not been feasible previously. Exposure assessments have typically been tied to residential locations, which ignore exposure within patterns of daily activities.

METHODS

We investigated the associations of exposure to multiple air pollutants, derived from nearest air quality monitors, with space-time asthma rescue inhaler use captured by digital sensors, in Jefferson County, Kentucky. A generalized linear mixed model, capable of accounting for repeated measures, over-dispersion and excessive zeros, was used in our analysis. A secondary analysis was done through the random forest machine learning technique.

RESULTS

The 1039 participants enrolled were 63.4% female, 77.3% adult (>18) and 46.8% White. Digital sensors monitored the time and location of over 286 980 asthma rescue medication uses and associated air pollution exposures over 193 697 patient-days, creating a rich spatiotemporal dataset of over 10 905 240 data elements. In the generalized linear mixed model, an interquartile range (IQR) increase in pollutant exposure was associated with a mean rescue medication use increase per person per day of 0.201 [95% confidence interval (CI): 0.189-0.214], 0.153 (95% CI: 0.136-0.171), 0.131 (95% CI: 0.115-0.147) and 0.113 (95% CI: 0.097-0.129), for sulphur dioxide (SO2), nitrogen dioxide (NO2), fine particulate matter (PM2.5) and ozone (O3), respectively. Similar effect sizes were identified with the random forest model. Time-lagged exposure effects of 0-3 days were observed.

CONCLUSIONS

Daily exposure to multiple pollutants was associated with increases in daily asthma rescue medication use for same day and lagged exposures up to 3 days. Associations were consistent when evaluated with the random forest modelling approach.

Expanding the Curriculum in a School of Public Health

Public health education has long been concentrated in a core set of public health disciplines such as epidemiology, biostatistics, and environmental health. Despite leaps forward in our understanding of the myriad influences on public health, little has changed in the organization of our educational systems. One issue brought to the forefront of public consciousness by the COVID-19 pandemic is the importance of leisure experiences, such as nature walks, to mental and physical well-being. In this descriptive best practice article, we discuss our approach to expanding the notion of a school of public health and provide examples of how disciplines and subjects outside of the “norms” of public health education, including leisure studies, can help better prepare students for their future in the field. Leisure studies is just one of many subject areas that can add value to public health pedagogy, and we envision many other subject areas and departments integrating into schools of public health in the future.

Need for clarifying remote physiologic monitoring reimbursement during the COVID-19 pandemic: a respiratory disease case study

The use of remote monitoring and virtual visits has accelerated to support socially-distanced patient care during the COVID-19 pandemic. Despite the necessity of this expansion, ambiguity in coding is hindering adoption and patient access, most notably for remote physiologic monitoring due to a lack of definition of the term “physiologic”. In this analysis, we describe the history of remote monitoring code development, present several examples in respiratory disease and other chronic conditions in which gaps and confusion remain and suggest ways to clarify and broaden coverage to ensure equitable access to remote monitoring.

Digital Health Technology in Asthma: A Comprehensive Scoping Review

BACKGROUND

A variety of digital intervention approaches have been investigated for asthma therapy during the past decade, with different levels of interactivity and personalization and a range of impacts on different outcome measurements.

OBJECTIVE

To assess the effectiveness of digital interventions in asthma with regard to acceptability and outcomes and evaluate the potential of digital initiatives for monitoring or treating patients with asthma.

METHODS

We evaluated digital interventions using a scoping review methodology through a literature search and review. Of 871 articles identified, 121 were evaluated to explore intervention characteristics, the perception and acceptability of digital interventions to patients and physicians, and effects on asthma outcomes. Interventions were categorized by their level of interactivity with the patient.

RESULTS

Interventions featuring non-individualized content sent to patients appeared capable of promoting improved adherence to inhaled corticosteroids, but with no identified improvement in asthma burden; and data-gathering interventions appeared to have little effect on adherence or asthma burden. Evidence of improvement in both adherence and patients' impairment due to asthma were seen only with interactive interventions involving two-way responsive patient communication. Digital interventions were generally positively perceived by patients and physicians. Implementation was considered feasible, with certain preferences for design and features important to drive use.

CONCLUSIONS

Digital health interventions show substantial promise for asthma disease monitoring and personalization of treatment. To be successful, future interventions will need to include both inhaler device and software elements, combining accurate measurement of clinical parameters with careful consideration of ease of use, personalization, and patient engagement aspects.

Health provider perspectives of electronic medication monitoring in outpatient asthma care: a qualitative investigation using the consolidated framework for implementation research

OBJECTIVE

Little is known about the implementation challenges health providers might face with the use of digital health in outpatient asthma care. To qualitatively explore the experience of health providers with electronic medication monitoring (EMM) using an implementation science framework.

METHODS

Using the Consolidated Framework of Implementation Research (CFIR), we conducted interviews (n = 10) exploring health providers' experience with EMM with asthma patients from 5 primary care or specialty clinics. The EMM tracked albuterol and inhaled corticosteroid (ICS) use, and health providers called parents whenever ICS adherence waned, or albuterol use increased. Interviews were audio-recorded, transcribed, and deductively analyzed using directed content analysis.

RESULTS

Health providers reported the intervention's primary advantage, compared with current asthma care, was the ability to monitor medication use at-home. Most felt the intervention improved care delivery. Nurses and medical assistants described a process of phone calls and checking alerts, that had varying levels of administrative burden and complexity. Health providers felt that sustained implementation of the intervention model would require additional employees to handle the administrative and clinical workload. Half of the interviewed providers were unsure if patient needs were met by the intervention, while some cited technology syncing issues, others liked the enhanced interactions for asthma education.

CONCLUSION

Health providers reported positive experiences supporting parents and children with asthma using EMM but also highlighted intervention components that needed improvement or refinement to yield successful implementation in outpatient pediatric clinics. Recommendations for enhancing the intervention for a scaled-up implementation were discussed.

Patient generated health data and electronic health record integration in oncologic surgery: A call for artificial intelligence and machine learning

In this review, we aim to assess the current state of science in relation to the integration of patient-generated health data (PGHD) and patient-reported outcomes (PROs) into routine clinical care with a focus on surgical oncology populations. We will also describe the critical role of artificial intelligence and machine-learning methodology in the efficient translation of PGHD, PROs, and traditional outcome measures into meaningful patient care models.

Systematic Review of mHealth Applications That Interface with Inhaler Sensors in Asthma

BACKGROUND

A better understanding of outcomes associated with mobile health (mHealth) applications (apps) for asthma self-management that pair with inhaler sensor technology is needed for clinicians to practice evidence-based medicine.

OBJECTIVE

To evaluate the effects of mHealth apps that integrate with an inhaler-based sensor on outcomes of patients with asthma.

METHODS

We performed a systematic review in GooglePlay and Apple App stores for consumer-facing mHealth apps for asthma management that pair with an inhaler-based sensor. We then searched for evidence evaluating these apps via PubMed and Cochrane Central (January 2007-May 2020), bibliographies on product websites, and www.clinicaltrials.gov. We included studies in patients with asthma evaluating apps discovered in the app stores on adherence or a health outcome of interest, and qualitatively summarized evidence.

RESULTS

We identified 6 mHealth apps and screened 2594 citations for evidence on these apps; 7 studies of 2 apps were included. Interventions modestly improved maintenance inhaler adherence and reduced rescue inhaler use but did not impact Asthma Control Test scores. Effects on exacerbations, quality of life, and pulmonary function were not evaluated in these studies.

CONCLUSIONS

The current literature evaluating mHealth apps paired with inhaler-based sensors focuses on a small number of available products and has limitations in quality. Positive effects on rescue inhaler use, inhaler adherence, and patient satisfaction were found. However, more comprehensive evaluation of products and their impact on health outcomes is needed before clinicians and patients can weigh the benefits against resources needed to adopt these technologies.

A decade of digital medicine innovation

The field of digital medicine has matured over the past decade, but validation will require careful randomized, controlled clinical trials.

Biomedical REAl-Time Health Evaluation (BREATHE): toward an mHealth informatics platform

OBJECTIVE

To describe a configurable mobile health (mHealth) framework for integration of physiologic and environmental sensors to be used in studies focusing on the domain of pediatric asthma.

MATERIALS AND METHODS

The Biomedical REAl-Time Health Evaluation (BREATHE) platform connects different sensors and data streams, contextualizing an individual's symptoms and daily activities over time to understand pediatric asthma's presentation and its management. A smartwatch/smartphone combination serves as a hub for personal/wearable sensing devices collecting data on health (eg, heart rate, spirometry, medications), motion, and personal exposures (eg, particulate matter, ozone); securely transmitting information to BREATHE's servers; and interacting with the user (eg, ecological momentary assessments). Server-side integration of electronic health record data and spatiotemporally correlated information (eg, weather, traffic) elaborates on these observations. An initial panel study involving pediatric asthma patients was conducted to assess BREATHE.

RESULTS

Twenty subjects were enrolled, during which BREATHE accrued seven consecutive days of continuous data per individual. The data were used to confirm knowledge about asthma (use of controller inhalers, time-activity behaviors, personal air pollution exposure), and additional analyses provided insights into within-day associations of environmental triggers and asthma exacerbations. Exit surveys focusing on mHealth usability, while positive, noted several translational challenges.

DISCUSSION

Based on these promising results, a longitudinal panel study to evaluate individual microenvironments and exposures is ongoing. Lessons learned thus far reflect the need to address various usability aspects, including convenience and ongoing engagement.

CONCLUSION

BREATHE enables multi-sensor mHealth studies, capturing new types of information alongside an evolving understanding of personal exposomes.

Improved asthma outcomes observed in the vicinity of coal power plant retirement, retrofit, and conversion to natural gas

Coal-fired power plants release substantial air pollution, including over 60% of U.S. sulfur dioxide (SO2) emissions in 2014. Such air pollution may exacerbate asthma however direct studies of health impacts linked to power plant air pollution are rare. Here, we take advantage of a natural experiment in Louisville, Kentucky, where one coal-fired power plant retired and converted to natural gas, and three others installed SO2 emission control systems between 2013 and 2016. Dispersion modeling indicated exposure to SO2 emissions from these power plants decreased after the energy transitions. We used several analysis strategies, including difference-in-differences, first-difference, and interrupted time-series modeling to show that the emissions control installations and plant retirements were associated with reduced asthma disease burden related to ZIP code-level hospitalizations and emergency room visits, and individual-level medication use as measured by digital medication sensors.

Structural and Social Determinants of Health in Asthma in Developed Economies: a Scoping Review of Literature Published Between 2014 and 2019

PURPOSE OF REVIEW

Using the WHO Conceptual Framework for Action on the Social Determinants of Health, this review provides a discussion of recent epidemiologic, mechanistic, and intervention studies of structural and social determinants of health and asthma outcomes covering the period from 2014 to 2019.

RECENT FINDINGS

A majority of studies and interventions to date focus on the intermediary determinants of health (e.g., housing), which as the name suggests, exist between the patient and the upstream structural determinants of health (e.g., housing policy). Race/ethnicity remains a profound social driver of asthma disparities with cumulative risk from many overlapping determinants. A growing number of studies on asthma are beginning to elucidate the underlying mechanisms that connect social determinants to human disease. Several effective interventions have been developed, though a need for large-scale policy research and innovation remains. Strong evidence supports the key role of the structural determinants, which generate social stratification and inequity, in the development and progression of asthma; yet, interventions in this realm are challenging to develop and therefore infrequent. Proximal, intermediary determinants have provided a natural starting point for interventions, though structural interventions have the most potential for major impact on asthma outcomes. Further research to investigate the interactive effect of multiple determinants, as well as intervention studies, specifically those that are cross-sector and propose innovative strategies to target structural determinants, are needed to address asthma morbidities, and more importantly, close the asthma disparity gap.

Food Insecurity and Major Diet-Related Morbidities in Migrating Children: A Systematic Review

Children of migrant families are known to be at a higher risk of diet-related morbidities due to complex variables including food insecurity, cultural and religious beliefs, and sociodemographic factors like ethnicity, socioeconomic status, and education. Several studies have assessed the presence of specific diseases related to dietary issues in migrant children. This systematic review aims to highlight the existing body of work on nutritional deficiencies in the specific vulnerable pediatric population of immigrants. Refugees were intentionally excluded because of fundamental differences between the two groups including the reasons for migration and health status at the time of arrival. A total of 29 papers were included and assessed for quality. Most of them described a strong correlation between obesity and migration. A high prevalence of stunting, early childhood caries, iron and vitamin D deficiency was also reported, but the studies were few and heterogeneous. Food insecurity and acculturation were found important social factors (nevertheless with inconclusive results) influencing dietary habits and contributing to the development of morbidities such as obesity and other metabolic disorders, which can cause progressive unsustainability of health systems. Public health screening for diet-related diseases in migrant children may be implemented. Educational programs to improve children’s diet and promote healthy-living behaviors as a form of socioeconomic investment for the health of the new generations may also be considered.

The Future of Asthma Care: Personalized Asthma Treatment

Although once considered a single disease entity, asthma is now known to be a complex inflammatory disease engaging a range of causal pathways. The most frequent forms of asthma are identified by sputum/blood eosinophilia and activation of type 2 inflammatory pathways involving interleukins-3, -4, -5, and granulocyte-macrophage colony-stimulating factor. The use of diagnostics that identify T2 engagement linked to the selective use of highly targeted biologics has opened up a new way of managing severe disease. Novel technologies, such as wearables and intelligent inhalers, enable real-time remote monitoring of asthma, creating a unique opportunity for personalized health care.

Smoke Sense Initiative Leverages Citizen Science to Address the Growing Wildfire-Related Public Health Problem

Smoke Sense is a citizen science project with investigative, educational, and action-oriented objectives at the intersection of wildland fire smoke and public health. Participants engage with a smartphone application to explore current and forecast visualizations of air quality, learn about how to protect health from wildfire smoke, and record their smoke experiences, health symptoms, and behaviors taken to reduce their exposures to smoke. Through participation in the project, individuals engage in observing changes in their environment and recording changes in their health, thus facilitating progression on awareness of health effects of air pollution and adoption of desired health-promoting behaviors. Participants can also view what others are reporting. Data from the pilot season (1 August 2017 to 7 January 2018; 5,598 downloads) suggest that there is a clear demand for personally relevant data during wildfire episodes motivated by recognition of environmental hazard and the personal concern for health. However, while participants shared clear perceptions of the environmental hazard and health risks in general, they did not consistently recognize their own personal health risk. The engagement in health protective behavior was driven in response to symptoms rather than as preventive courses of action. We also observed clear differences in the adoption likelihood of various health protective behaviors attributed to barriers and perceived benefits of these actions. As users experience a greater number and severity of symptoms, the perceived benefits of taking health protective actions exceeded the costs associated with the barriers and thus increased adoption of those actions. Based on pilot season data, we summarize key insights which may improve current health risk communications in nudging individuals toward health protective behavior; there is a need to increase personal awareness of risk and compelling evidence that health protective behaviors are beneficial.

Patient generated health data use in clinical practice: A systematic review

BACKGROUND

Precision health calls for collecting and analyzing large amounts of data to capture an individual's unique behavior, lifestyle, genetics, and environmental context. The diffusion of digital tools has led to a significant growth of patient generated health data (PGHD), defined as health-related data created, gathered or inferred by or from patients and for which the patient controls data collection and data sharing.

PURPOSE

We assessed the current evidence of the impact of PGHD use in clinical practice and provide recommendations for the formal integration of PGHD in clinical care.

METHODS

We searched PubMed, Ovid, Embase, CINAHL, Web of Science, and Scopus up to May 2018. Inclusion criteria were applied and four reviewers screened titles and abstracts and consequently full articles.

FINDINGS

Our systematic literature review identified 21 studies that examined the use of PGHD in clinical settings. Integration of PGHD into electronic records was extremely limited, and decision support capabilities were for the most part basic.

DISCUSSION

PGHD and other types of patient-reported data will be part of the health care system narrative and we must continue efforts to understand its impact on health outcomes, costs, and patient satisfaction. Nursing scientists need to lead the process of defining the role of PGHD in the era of precision health.

Comparing Written Versus Pictorial Asthma Action Plans to Improve Asthma Management and Health Outcomes Among Children and Adolescents: Protocol of a Pilot and Feasibility Randomized Controlled Trial

Background

Asthma is an important focus for pediatric health research as management of asthma symptoms is a significant challenge, and morbidity and mortality among youths with asthma remain prevalent. Treatment guidelines for asthma recommend a written asthma action plan (WAAP) that summarizes individualized instructions for daily medication use. However, WAAPs are typically written at a seventh- to ninth-grade reading level, which can be a barrier to young people in understanding their treatment, having confidence in using a WAAP, and engaging with asthma education.

Objective

Utilizing a feasibility and pilot randomized controlled trial (RCT) design, the objective of the Take Action for Asthma Control study is to test a symptom-based, computer-generated pictorial asthma action plan (PAAP) in comparison with a standard WAAP and assess the feasibility and acceptability of the asthma action plan (AAP) intervention and study procedures. The study has 3 aims: (1) estimate the effect sizes of PAAPs compared with WAAPs on outcomes (eg, AAP knowledge and medication adherence), (2) evaluate feasibility and acceptability of AAP intervention and RCT procedures from the perspectives of key stakeholders, and (3) establish whether parent and youth literacy levels are associated with treatment outcomes.

Methods

This feasibility and pilot RCT is a block randomized, 2-arm, parallel-group clinical trial, lasting 6 months in duration. At baseline, participants will be randomly assigned to receive a PAAP or WAAP generated for them and reviewed with them by their asthma physician. Study procedures will take place over 4 separate time points: a baseline clinic appointment, 1-month telephone follow-up, and 3- and 6-month clinic-based follow-ups. At each time point, data will be collected related to the main outcomes: AAP knowledge, AAP satisfaction, asthma control, pulmonary function, and adherence to daily asthma medication. A sample size of up to 60 participants (aged 8-17 years) will be recruited. Feasibility and acceptability data will be collected via one-to-one qualitative interviews with providers involved in the study and a subgroup of families that participate in the study.

Results

Recruitment and data collection began in May 2017 and were completed in October 2018.

Conclusions

This pilot and feasibility study will test the potential efficacy, feasibility, and acceptability of an AAP intervention and study procedures. The findings will inform the design and delivery of a future definitive trial to assess the efficacy of PAAPs versus WAAPs in supporting asthma self-management among children and adolescents.

International Registered Report Identifier (IRRID)

DERR1-10.2196/11733

Rubbertown Next Generation Emissions Measurement Demonstration Project

Industrial facilities and other sources can emit air pollutants from fugitive leaks, process malfunctions and area sources that can be difficult to understand and to manage. Next generation emissions measurement (NGEM) approaches executed near facilities are enabling new ways to assess these sources and their impacts to nearby populations. This paper describes complementary uses of emerging NGEM systems in a Louisville, KY industrial district (Rubbertown), focusing on an important area air toxic, 1,3-butadiene. Over a one-year deployment starting in September 2017, two-week average passive samplers (PSs) at 11 sites showed both geospatial and temporal trends. At 0.24 ppbv annual average 1,3-butadiene concentration, a group of PSs located near facility fence lines was elevated compared to a PS group located in the community and upwind from facilities (0.07 ppbv average). Two elevated PS periods capturing emission events were examined using time-resolved NGEM approaches as case studies. In one event a 1.18 ppbv PS reading was found to be relatively localized and was caused by a multiday emission from a yet to be identified, non-facility source. In the other event, the airshed was more broadly impacted with PS concentrations ranging from 0.71 ppbv for the near-facility group to 0.46 ppbv for the community group. This case was likely influenced by a known emission event at an industrial facility. For both case studies, air pollutant and wind data from prototype NGEM systems were combined with source location models to inform the emission events. This research illustrates the power of applying NGEM approaches to improve both the understanding of emissions near sources and knowledge of impacts to near-source communities.

Connected drug delivery devices to complement drug treatments: potential to facilitate disease management in home setting

Connected drug delivery devices are increasingly being developed to support patient supervision and counseling in home setting. Features may include dosing reminders, adherence trackers, tools for patient education, and patient diaries to collect patient-reported outcomes, as well as monitoring tools with interfaces between patients and health care professionals (HCPs). Five connected devices have been selected as the basis for a review of the clinical evidence concerning the impact of electronic tools on treatment adherence and efficacy outcomes. Disease areas covered include multiple sclerosis, diabetes, hypertension, liver and renal transplant recipients, tuberculosis, hepatitis C, clinically isolated syndrome, asthma, and COPD. From studies comparing the use of electronic feedback tools to standard of care, there is an initial evidence for a higher adherence to treatment and better outcomes among patients who use the electronic tools. To substantiate the assumption that connected devices can improve adherence in an outpatient setting over a prolonged period of time, further data from controlled randomized studies are required. Key barriers to the broader adoption of connected devices include data privacy laws that may prevent data sharing with HCPs in some countries, as well as the need to demonstrate that the tools are consistently used and generate a high-quality and reproducible database. If these challenges can be addressed in a way that is agreeable to all stakeholders, it is expected that the future value of connected devices will be to 1) facilitate and improve patient involvement in disease management in a flexible care setting, 2) enable early treatment decisions, and 3) complement value-based reimbursement models.

Harmonized outcome measures for use in asthma patient registries and clinical practice

BACKGROUND

Asthma, a common chronic airway disorder, affects an estimated 25 million persons in the United States and 330 million persons worldwide. Although many asthma patient registries exist, the ability to link and compare data across registries is hindered by a lack of harmonization in the outcome measures collected by each registry.

OBJECTIVES

The purpose of this project was to develop a minimum set of patient- and provider-relevant standardized outcome measures that could be collected in asthma patient registries and clinical practice.

METHODS

Asthma registries were identified through multiple sources and invited to join the workgroup and submit outcome measures. Additional measures were identified through literature searches and reviews of quality measures and consensus statements. Outcome measures were categorized by using the Agency for Healthcare Research and Quality's supported Outcome Measures Framework. A minimum set of broadly relevant measures was identified. Measure definitions were harmonized through in-person and virtual meetings.

RESULTS

Forty-six outcome measures, including those identified from 13 registries, were curated and harmonized into a minimum set of 21 measures in the Outcome Measures Framework categories of survival, clinical response, events of interest, patient-reported outcomes, resource utilization, and experience of care. The harmonized definitions build on existing consensus statements and are appropriate for adult and pediatric patients.

CONCLUSIONS

The harmonized measures represent a minimum set of outcomes that are relevant in asthma research and clinical practice. Routine and consistent collection of these measures in registries and other systems would support creation of a national research infrastructure to efficiently address new questions and improve patient management and outcomes.

Delivery Technologies for Orally Inhaled Products: an Update

Orally inhaled products have well-known benefits. They allow for effective local administration of many drugs for the treatment of pulmonary disease, and they allow for rapid absorption and avoidance of first-pass metabolism of several systemically acting drugs. Several challenges remain, however, such as dosing limitations, low and variable deposition of the drug in the lungs, and high drug deposition in the oropharynx region. These challenges have stimulated the development of new delivery technologies. Both formulation improvements and new device technologies have been developed through an improved understanding of the mechanisms of aerosolization and lung deposition. These new advancements in formulations have enabled improved aerosolization by controlling particle properties such as density, size, shape, and surface energy. New device technologies emerging in the marketplace focus on minimizing patient errors, expanding the range of inhaled drugs, improving delivery efficiency, increasing dose consistency and dosage levels, and simplifying device operation. Many of these new technologies have the potential to improve patient compliance. This article reviews how new delivery technologies in the form of new formulations and new devices enhance orally inhaled products.

Telemedicine Technology: a Review of Services, Equipment, and Other Aspects

PURPOSE OF REVIEW

Telemedicine uses technology to connect patients with providers at a distance. While the clinical aspects of this have been reviewed extensively, the technical aspects are not as well understood by allergists when they consider adding telemedicine to their practice. This review focuses on the technical aspects of setting up a telemedicine program.

RECENT FINDINGS

With the advent of new technologies including high-speed Internet, video conferencing solutions, and digital examination equipment, facilitated virtual visits as replacements for in-person visits are now possible. The technical requirements for a successful telemedicine program include secure, high-speed Internet connection, a clinical telemedicine cart to serve as the hub for the interaction, patient access software, and access to IT professionals to set up the program and to be available when the system malfunctions. A carefully designed telemedicine program is more likely to be successful if the technical aspects are included in the planning process.