Development and validation of an electronic daily control score for asthma (e-DASTHMA): a real-world direct patient data study

BACKGROUND

Validated questionnaires are used to assess asthma control over the past 1-4 weeks from reporting. However, they do not adequately capture asthma control in patients with fluctuating symptoms. Using the Mobile Airways Sentinel Network for airway diseases (MASK-air) app, we developed and validated an electronic daily asthma control score (e-DASTHMA).

METHODS

We used MASK-air data (freely available to users in 27 countries) to develop and assess different daily control scores for asthma. Data-driven control scores were developed based on asthma symptoms reported by a visual analogue scale (VAS) and self-reported asthma medication use. We included the daily monitoring data from all MASK-air users aged 16-90 years (or older than 13 years to 90 years in countries with a lower age of digital consent) who had used the app in at least 3 different calendar months and had reported at least 1 day of asthma medication use. For each score, we assessed construct validity, test-retest reliability, responsiveness, and accuracy. We used VASs on dyspnoea and work disturbance, EQ-5D-VAS, Control of Allergic Rhinitis and Asthma Test (CARAT), CARAT asthma, and Work Productivity and Activity Impairment: Allergy Specific (WPAI:AS) questionnaires as comparators. We performed an internal validation using MASK-air data from Jan 1 to Oct 12, 2022, and an external validation using a cohort of patients with physician-diagnosed asthma (the INSPIRERS cohort) who had had their diagnosis and control (Global Initiative for Asthma [GINA] classification) of asthma ascertained by a physician.

FINDINGS

We studied 135 635 days of MASK-air data from 1662 users from May 21, 2015, to Dec 31, 2021. The scores were strongly correlated with VAS dyspnoea (Spearman correlation coefficient range 0·68-0·82) and moderately correlated with work comparators and quality-of-life-related comparators (for WPAI:AS work, we observed Spearman correlation coefficients of 0·59-0·68). They also displayed high test-retest reliability (intraclass correlation coefficients range 0·79-0·95) and moderate-to-high responsiveness (correlation coefficient range 0·69-0·79; effect size measures range 0·57-0·99 in the comparison with VAS dyspnoea). The best-performing score displayed a strong correlation with the effect of asthma on work and school activities in the INSPIRERS cohort (Spearman correlation coefficients 0·70; 95% CI 0·61-0·78) and good accuracy for the identification of patients with uncontrolled or partly controlled asthma according to GINA (area under the receiver operating curve 0·73; 95% CI 0·68-0·78).

INTERPRETATION

e-DASTHMA is a good tool for the daily assessment of asthma control. This tool can be used as an endpoint in clinical trials as well as in clinical practice to assess fluctuations in asthma control and guide treatment optimisation.

FUNDING

None.

[Environmental intervention in respiratory disease]

In recent years there has been a significant increase in the prevalence of allergic diseases despite advances in the understanding of the pathogenesis, the dissemination of guidelines for its management and the emergence of new drugs. The reasons for this increase are not fully established, but it is suggested that multiple environmental factors may be involved. Inhaled air contains numerous harmful agents in addition to environmental allergens. The main immediate respiratory clinical expression after inhaling this contaminated air is asthma and rhinitis. The activity of human beings has altered the outdoor environment by the emission of multiple pollutants and has produced an increasing climate change. It also has a notable impact on the development of respiratory pathology and the modification of air quality. The bibliography on the subject of environmental control is very broad and sometimes difficult to interpret. In order to be able to make precise, valid and simple indications for patients to accomplish with, four scientific societies of the Argentine Republic that deal with this type of diseases, have elaborated a document that contains information of easy access to all medical personal involved in the treatment of patients with asthma and / or rhinitis, that provides practical measures for the patients and the different public health systems about unmet needs in this complex issue.

Mite sensitivity and exposure in the city of Santa Fe, Argentina

Little information is available on mite allergen levels and rates of sensitization to domestic mites in South America. The purpose of this study was to establish the rate of sensitization to domestic mites in asthmatics and measure mite allergen levels in pillows and mattresses of mite allergic individuals in Santa Fe, Argentina. Dust samples were collected from the pillows and mattresses of 56 asthmatics (24 females and 32 males, mean age 17.6 +/- 11.5 years), who had been previously skin tested with standardized extracts of Dermatophagoides pteronyssinus, Dermatophagoides farinae and (1:50 w/v) extracts of Aleuroglyphus ovatus, Blomia tropicalis, Chortoglyphus arcuatus. A wheal > or = 3 mm was considered positive. Sensitization to Lepidoglyphus destructor and Euroglyphus maynei was determined by RAST and considered positive when a serum bound > or = 1% of the total counts added. Forty six individuals had a positive skin test to D. pteronyssinus, 43 to D. farinae, 27 to A. ovatus, 38 to B. tropicalis, 27 to C. arcuatus; 38 of 54 individuals had a positive RAST to E. maynei and 22 of 54 to L. destructor. The mean Group 1 (Der p 1 + Derf 1) level in pillows (n = 48) was 6.7 micrograms/g (1-55.4) and in mattresses (n = 52) 4.3 micrograms/g (1-38.8). There is a high degree of sensitization to domestic mites among asthmatics in Santa Fe. High mite allergen levels (> 2 micrograms/g) can be detected very often in pillows and mattresses.

Cutaneous sensitivity to six mite species in asthmatic patients from five Latin American countries

The prevalence of positive skin prick tests to the mite species Dermatophagoides pteronyssinus, D. farinae, Blomia tropicalis, Chortoglyphus arcuatus, Lepidoglyphus destructor and Aleuroglyphus ovatus was determined in 297 asthmatic adults and children living in seven cities of five Latin American countries. A standardized protocol and a common battery of extracts were used at each site. The mean wheal diameters were measured after 15 min, and those > or = 3 mm were considered positive. Sensitization to D. pteronyssinus varied from 60.7% in Cartagena to 91.2% in São Paulo; to D. farinae from 53.3% in Córdoba to 97.2% in Caracas; to A. ovatus from 26.6% in Bogotá to 71.2% in São Paulo; to B. tropicalis from 46.5% in Mexico City to 93.7% in São Paulo; to C. arcuatus from 33.3% in Mexico City to 75% in São Paulo; and to L. destructor from 30% in Mexico City to 76.2% in São Paulo. This study reported the results of skin test sensitivities in both children and adults. The studies from São Paulo and Córdoba were confined to children and thus could be compared; there was a significantly higher prevalence of cutaneous sensitivity to mite allergens in the children of São Paulo than in those of Córdoba (p < 0.001 for all mite species). Cutaneous sensitivity to mite allergens is very common in young and adult asthmatics in Latin America, in areas both at sea level and at high altitudes. Environmental control measures should be reinforced in the treatment of asthmatics in Latin America.

[Pharmaco-prevention of bronchial asthma using membrane stabilizers and asthma mortality]

The increase in the incidence of bronchial asthma is not necessarily accompanied by an increase in death rates; furthermore, the knowledge of the intimate physiopathogenic mechanisms of the disease, the appearance of new drugs with pharmaceutical forms that make them more available for patients, should improve the effectiveness of the treatment. In spite of that, the asthma death rate curves increase as drug sales increase. Some authors think this is caused by factors depending on the patient, the health system and, nowadays, the inappropriate use of the available drugs is thought to be one of the reasons for the increase in asthma death rates, and the use of drugs that only supply to the patient an adequate bronchodilation may mask the underlying inflammatory process, what unavoidably leads to irreversible deteriorations in the airways, with smooth muscle hypertrophy and thickening of the basal membrane. It is logical to think that children's bronchial asthma is the first stage of a progressive illness, in which the allergic factor is really meaningful, and that is why a suitable prophylaxis with early use of drugs with antiinflammatory activity may prevent the development of irreversible deteriorations of bronchial and lung parenchyma. Oral or inhalatant corticoids, disodium cromoglycate, ketotifen and nedocromil are the drugs with well-known antiinflammatory activity, though they have a different site of action, as corticoids act directly on inflammatory cells, inhibiting the activity of macrophages and particularly of eosinophils, while cromoglycate, nedocromil and ketotifen inhibit mediators release, thus stabilizing mastocyte membrane.