Impact of Clinical Characteristics and Biomarkers on AIRQ Exacerbation Prediction Ability

BACKGROUND

Complex models combining impairment-based control assessments with clinical characteristics and biomarkers have been developed to predict asthma exacerbations. The composite Asthma Impairment and Risk Questionnaire (AIRQ) with adjustments for demographics (age, sex, race, body mass index [BMI]) predicts 12-month exacerbation occurrence similarly to these more complex models.

OBJECTIVE

To examine whether AIRQ exacerbation prediction is enhanced when models are adjusted for a wider range of clinical characteristics and biomarkers.

METHODS

Patients aged ≥12 years completed monthly online surveys regarding exacerbation-related oral corticosteroid use, emergency-department/urgent-care visits, and hospitalizations. Univariate logistic regressions to predict exacerbations were performed with sociodemographics, comorbidities, exacerbation history, lung function, blood eosinophils, immunoglobulin E, and fractional exhaled nitric oxide. Significant (P≤0.05) variables were included in multivariable logistic regressions with and without AIRQ control categories to predict 12-month exacerbations (log odds ratio [OR], 95% Wald confidence interval [CI]). Model performances were compared.

RESULTS

Over 12 months, 1070 patients (70% female; mean[SD] age 43.9[19.4] years; 22% non-White; BMI[SD] 30.6[8.7]) completed ≥1 survey (mean[SD] 10.5[2.8]). In the multivariable analysis, AIRQ control category adjusted for significant clinical characteristics and biomarkers was predictive of ≥1 exacerbation: OR(95%CI) not well-controlled vs well-controlled: 1.93(1.41-2.62), very poorly controlled vs well-controlled: 3.81(2.65-5.47). Receiver operating characteristic area under the curve for this more complex model of exacerbation prediction (AUC=0.72) did not differ from AIRQ (AUC=0.70). Models with AIRQ performed better than those without AIRQ (AUC=0.67, P<0.05).

CONCLUSION

Costly and time-consuming complex modeling with clinical characteristics and biomarkers does not enhance the strong exacerbation prediction ability of AIRQ.

Advancing assessment of asthma control with a composite tool: The Asthma Impairment and Risk Questionnaire

BACKGROUND

National and international asthma guidelines and reports do not include control tools that combine impairment assessment with exacerbation history in one instrument.

OBJECTIVE

To analyze the performance of the composite Asthma Impairment and Risk Questionnaire (AIRQ) in assessing both domains of control and predicting exacerbation risk compared with the Global Initiative for Asthma (GINA) 4-question symptom control tool (GINA SCT), Asthma Control Test (ACT), and physician expert opinion (EO) informed by GINA SCT responses and appraisal of GINA-identified risk factors for poor asthma outcomes.

METHODS

Multivariable logistic regressions evaluated AIRQ and GINA SCT as predictors of ACT. McNemar's test compared the proportion of patients categorized at baseline as completely or well-controlled by each assessment but with current impairment or previous-year and subsequent-year exacerbations.

RESULTS

The analysis included 1064 patients aged 12 years or older; mean (SD) age 43.8 years (19.3); 70% female; 79% White; and 6% Hispanic or Latino. AIRQ and GINA SCT were highly predictive of ACT well-controlled vs not well-controlled and very poorly controlled (receiver operator characteristic area under curve AIRQ = 0.90, GINA SCT = 0.86, P = .03 AIRQ vs GINA SCT) and ACT very poorly controlled vs well-controlled and not well-controlled asthma (receiver operator characteristic area under curve AIRQ = 0.91, GINA SCT = 0.87, P = .01 AIRQ vs GINA SCT). AIRQ rated fewer patients as having completely or well-controlled asthma who had current impairment (P < .01) or with previous-year and subsequent-year exacerbations (P < .001) than did GINA SCT, ACT, and EO.

CONCLUSION

AIRQ performs better in assessing both domains of current control and predicting exacerbation risk than do control tools and EO informed by GINA SCT and risk factors for poor asthma outcomes.

Assessing meaningful change in the Asthma Impairment and Risk Questionnaire

BACKGROUND

The Asthma Impairment and Risk Questionnaire (AIRQ) is a 10-item, yes/no, equally weighted control tool. Lower scores indicate better control. Moreover, 7 impairment items reflect previous 2-week symptoms, and 3 risk items assess previous 12-month exacerbations. The Follow-up AIRQ for use between annual assessments has a 3-month recall period for exacerbation items.

OBJECTIVE

To evaluate the responsiveness of the AIRQ over time and identify a minimal important difference (MID).

METHODS

The AIRQ longitudinal study data were analyzed from patients with asthma aged 12 years and older. Anchor-based methods assessed differences in AIRQ scores relative to Patient Global Impression of Change, the accepted MIDs for St. George's Respiratory Questionnaire and Asthma Control Test, and exacerbation occurrence over 12 months. Baseline and 12-month data reflected 12-month recall AIRQ scores; Follow-up AIRQ scores were used for 3-, 6-, and 9-month analyses.

RESULTS

A total of 1070 patients were included. The Patient Global Impression of Change rating of "much improved" was associated with AIRQ mean score changes from baseline to months 3, 6, 9, and 12 of -2.0, -1.9, -1.9, and -1.8, respectively. The mean AIRQ score change among patients who met the St. George's Respiratory Questionnaire MID (≥4-point decrease) was -1.8 at 6 and 12 months. The AIRQ mean scores decreased from baseline by -2.2 to -2.5 points at months 3, 6, 9, and 12 for patients who met the Asthma Control Test MID (≥ 3-point increase). A 2-point higher baseline AIRQ score was associated with a 1.7 odds ratio of 12-month exacerbation occurrence (95% CI, 1.53-1.89).

CONCLUSION

A change score of 2 is recommended as the AIRQ MID.

The Asthma Impairment and Risk Questionnaire enhances the assessment of asthma control

BACKGROUND

Asthma control is often overestimated in routine practice, and despite advances in the understanding of immunopathology and the availability of new precision therapies, the burden of disease remains unacceptably high.

OBJECTIVE

To compare the performance of the Asthma Impairment and Risk Questionnaire (AIRQ) with patient and physician assessments and the Asthma Control Test (ACT) in identifying asthma control.

METHODS

Baseline data from a longitudinal study of the AIRQ were analyzed. Patients with asthma in the United States aged 12 years and older followed in 24 specialty practices and 1 specialty-affiliated primary care clinic were enrolled between May and November 2019. At entry, participants completed AIRQ and ACT, and participants and physicians completed 5-point Likert scale assessments of control.

RESULTS

A total of 1112 participants were enrolled (mean [SD] age = 43.9 [19.3] years, 70% of the female sex, 78% White). Overall, 62% of participants rated themselves as well- or completely controlled, and 54% were rated comparably by physicians. The ACT classified 49% of participants as well-controlled, with 35% similarly categorized by AIRQ. Previous-year exacerbations were experienced by 32% of participants who self-rated as well- or completely controlled, 30% who were rated as well- or completely controlled by physicians, and 29% assessed as well-controlled by ACT, but only 15% of those classified as well-controlled by AIRQ.

CONCLUSION

The burden of asthma is substantial in patients cared for by asthma specialists, and asthma control is overestimated by patients, physicians, and the symptom-based ACT. The AIRQ assesses risk in addition to symptom control and may serve to improve asthma control determination by assessing previous exacerbations.

Real-world experience of pediatric patients treated with peanut (Arachis hypogaea) allergen powder-dnfp

BACKGROUND

Peanut (Arachis hypogaea) allergen powder-dnfp (PTAH) is the first oral immunotherapy indicated for children aged 4 to 17 years with peanut allergy. There are limited real-world data on patients treated with PTAH.

OBJECTIVE

To characterize pediatric patients treated with PTAH and associated treatment patterns in US clinical practice.

METHODS

US-based physicians with allergy and immunology training treating patients with peanut allergy aged 4 to 17 years with PTAH were recruited from an existing physician panel and completed an online case report form (October to December 2021) with data abstracted from patient medical charts. Physician practice circumstances, patient characteristics, and PTAH treatment patterns were reported. Time to reach the 300-mg dose and treatment persistence were assessed using Kaplan-Meier analysis.

RESULTS

A geographically balanced sample of 43 physicians contributed data for 118 demographically diverse pediatric patients. Patients had heterogeneous diagnostic test results, with a wide range of peanut-specific immunoglobulin E levels; 6.8% received an oral food challenge. During the updosing phase, there were no temporary interruptions and 5.1% of the patients required downdosing. Patients reached the 300-mg dose at a median of 21.3 weeks post-initiation. The rate of PTAH persistence at 24 weeks was 93.4%. Only 1 patient discontinued treatment because of treatment-related systemic allergic symptoms, and the remaining discontinuations were for reasons other than treatment-related symptoms. Prophylactic antihistamines were used by 33.9% of the patients to prevent PTAH adverse effects.

CONCLUSION

PTAH was prescribed in demographically diverse patients with a wide range of peanut-specific immunoglobulin E levels. Treatment persistence with PTAH was high in this study population, with a small number of patients experiencing treatment modification.

Relationship Between Asthma Control as Measured by the Asthma Impairment and Risk Questionnaire (AIRQ) and Patient Perception of Disease Status, Health-Related Quality of Life, and Treatment Adherence

Purpose

Critical asthma outcomes highlighted in clinical guidelines include asthma-related quality of life, asthma exacerbations, and asthma control. An easy-to-implement measure of asthma control that assesses both symptom impairment and exacerbation risk and reflects the impact of asthma on patients' lives is lacking. Hence, the objective of this study was to assess the Asthma Impairment and Risk Questionnaire (AIRQ^®) construct validity relative to patient self-perception of asthma status and validated disease-specific patient-reported outcome (PRO) measures.

Patients and methods

Baseline data were analyzed from patients (aged ≥ 12 years) with asthma participating in a 12-month observational study assessing the ability of AIRQ to predict exacerbations. At entry, patients completed a sociodemographic questionnaire, AIRQ, 3 questions addressing self-perceived asthma status, Saint George's Respiratory Questionnaire (SGRQ), mini-Asthma Quality of Life Questionnaire (AQLQ), and Adult Asthma Adherence Questionnaire (AAAQ). Descriptive statistics were calculated for demographic and clinical characteristics. AIRQ construct validity was evaluated by assessing correlations between total AIRQ score and patient self-assessments, SGRQ, mini-AQLQ, and AAAQ scores. Comparisons of SGRQ, mini-AQLQ, and AAAQ total and component/domain scores by AIRQ control category were performed using general linear models and Scheffe's post hoc adjustments for pairwise comparisons.

Results

A total of 1112 patients were enrolled: 70% female, 78% White, mean (standard deviation) age 43.9 (19.5) years. There were highly significant correlations between AIRQ score and patient self-perception of overall control (r = 0.69; p < 0.001), total SGRQ (r = 0.74, p < 0.001), and mini-AQLQ (r = -0.78, p < 0.001) scores. As AIRQ control category worsened, so did total and domain SGRQ, mini-AQLQ, and AAAQ impediment-to-inhaled-corticosteroid-adherence scores (all pairwise comparisons p < 0.001).

Conclusion

Findings demonstrate the construct validity of AIRQ relative to patient self-perception of asthma status, disease-specific PRO measures, and treatment adherence barriers. AIRQ can be a useful instrument to raise awareness of the unrecognized impacts of asthma on patients' lives.

The Asthma Impairment and Risk Questionnaire (AIRQ) Control Level Predicts Future Risk of Asthma Exacerbations

BACKGROUND

The Asthma Impairment and Risk Questionnaire (AIRQ) is a 10-item, equally weighted, yes/no control tool validated in patients with asthma aged 12 years and older.

OBJECTIVE

To evaluate AIRQ's ability to predict patient-reported exacerbations over 12 months.

METHODS

Patients completed a baseline AIRQ during an in-person enrollment visit and reported exacerbations (ie, asthma-related courses of oral corticosteroids, emergency department/urgent care visits, and hospitalizations) via monthly online surveys. Logistic regressions were performed using AIRQ control level (well-controlled [WC], not well-controlled [NWC], very poorly controlled [VPC]), age, sex, race, and body mass index as covariates and 1 or more and 2 or more exacerbations as the dependent variables (adjusted odds ratios [OR] and 95% Wald CIs). Kaplan-Meier analyses of time to first exacerbation by AIRQ control level were performed.

RESULTS

A total of 1,112 patients were enrolled; 1,070 completed 1 or more surveys over 12 months (mean ± SD 10.5 ± 2.8 months); 70.5% female; age 43.9 ± 19.3 years; 20.4% non-White; body mass index 30.6 ± 8.7 kg/m²; AIRQ: WC 35.2%, NWC 38.1%, VPC 26.6%. A total of 45.7% of patients reported 1 or more exacerbations and 26.7% 2 or more exacerbations (WC 28.4% ≥ 1, 11.1% ≥ 2; NWC 46.3% ≥ 1, 27.9% ≥ 2; VPC 67.7% ≥ 1, 45.6% ≥ 2). The ORs for 1 or more exacerbations NWC versus WC were 2.1 (CI 1.6-2.9), and VPC versus WC were 4.6 (CI 3.3-6.5). The ORs for 2 or more exacerbations NWC versus WC were 3.1 (CI 2.1-4.6), and VPC versus WC were 6.1 (CI 4.0-9.1). Kaplan-Meier curves demonstrated clear differentiation of time to first exacerbation by AIRQ control level (P < .001).

CONCLUSIONS

The AIRQ control level predicts exacerbation risk over 12 months and probability of time to first exacerbation.

Physical Activity Before, During, and After Chemotherapy for High-Risk Breast Cancer: Relationships With Survival

BACKGROUND

Although physical activity has been consistently associated with reduced breast cancer mortality, evidence is largely based on data collected at one occasion. We examined how pre- and postdiagnosis physical activity was associated with survival outcomes in high-risk breast cancer patients.

METHODS

Included were 1340 patients enrolled in the Diet, Exercise, Lifestyle and Cancer Prognosis (DELCaP) Study, a prospective study of lifestyle and prognosis ancillary to a SWOG clinical trial (S0221). Activity before diagnosis, during treatment, and at 1- and 2-year intervals after enrollment was collected. Patients were categorized according to the Physical Activity Guidelines for Americans as meeting the minimum guidelines (yes/no) and incrementally as inactive, low active, moderately active (meeting the guidelines), or high active.

RESULTS

In joint-exposure analyses, patients meeting the guidelines before and 1 year after diagnosis experienced statistically significant reductions in hazards of recurrence (hazard ratio [HR] = 0.59, 95% confidence interval [CI] = 0.42 to 0.82) and mortality (HR = 0.51, 95% CI = 0.34-0.77); associations were stronger at 2-year follow-up for recurrence (HR = 0.45, 95% CI = 0.31 to 0.65) and mortality (HR = 0.32, 95% CI = 0.19 to 0.52). In time-dependent analyses, factoring in activity from all time points, we observed striking associations with mortality for low- (HR = 0.41, 95% CI = 0.24 to 0.68), moderate- (HR = 0.42, 95% CI = 0.23 to 0.76), and high-active patients (HR = 0.31, 95% CI = 0.18 to 0.53).

CONCLUSIONS

Meeting the minimum guidelines for physical activity both before diagnosis and after treatment appears to be associated with statistically significantly reduced hazards of recurrence and mortality among breast cancer patients. When considering activity from all time points, including during treatment, lower volumes of regular activity were associated with similar overall survival advantages as meeting and exceeding the guidelines.

The Peanut Allergy Burden Study: Real-world impact of peanut allergy on resource utilization and productivity

Background

There is limited research demonstrating the real-world economic burden of peanut allergy (PA) in the United States. The Peanut Allergy Burden Study (PABS) is a cross-sectional quantitative survey designed to determine the real-world experience of patients and caregivers with PA. The objective of the study was to understand the real-world utilization of PA-related healthcare resources and the impact of PA on productivity.

Methods

Participants completed an online survey to examine the real-world 12-month and lifetime healthcare utilization and past week productivity impact of PA in children (as reported by caregiver proxy), adolescents with PA, adults with PA, and caregivers of children with PA.

Results

Healthcare resource use over the past 12 months was frequent for adults (n = 153), adolescents (n = 102), and children (as reported by caregivers) (n = 382) with PA. Patients and caregivers reported the following rates of PA-related utilization in the past 12 months: at least 3 regular allergist appointments (28.8%–39.3%), unscheduled allergist appointments (15.6%–18.3%), general practitioner appointments (16.7%–24.2%), over-the-counter (OTC) medication usage (28.5%–35.7%), and epinephrine autoinjector usage (17.7%–26.2%). Additionally, over half of patients and caregivers reported ≥1 PA-related emergency department (ED)/urgent care visit (57.5%–59.9%), overnight hospital admission (36.3%–47.4%), IV epinephrine use (37.2%–52.3%), or intubation (26.2%–39.8%) over the past 12 months for PA. Healthcare resource use was high among all groups. Regarding productivity, PA significantly impacted household work, schoolwork, and employed work for patients and caregivers. PA-related reactions also impacted school attendance of children with PA.

Conclusion

Many healthcare resources were utilized by patients with PA and there was a loss of productivity associated with PA for patients and caregivers. New treatments to prevent or lower the risk of PA reactions could potentially help reduce healthcare resource utilization and PA-related productivity loss among patients and their families, particularly for patients for whom avoidance as a treatment strategy has not been reliable.

Validation of inducible basophil biomarkers: Time, temperature and transportation

Background

The short stability window of several hours from blood collection to measuring basophil activation has limited the use of flow cytometry‐based basophil activation assays in clinical settings. We examine if it is possible to extend this window to 1 day allowing for shipment of samples between laboratories. Several options exist for reporting the results including reporting all the measured values directly, calculating ratios and reporting a single value covering all measured results. Each of these options have different stability and value to the physician.

Methods

Whole blood samples from peanut allergic patients were stimulated with four different peanut concentrations at Day 0, Day 1, and Day 2. Samples were stored under temperature‐controlled conditions. Flow cytometry was used to analyze the samples. The basophil activation and degranulation were measured as percentage of positive CD63 basophils and CD203c MFI fold change. Shipped samples were transported under ambient conditions.

Results

The results show that CD63 is a stable marker at Day 1. The CD203c ratio decreases significantly at Day 1. Calculating the CD63/IgE ratio proves to be more stable than CD63 alone. The most stable readouts are the semi‐quantitative results and the trajectory of the dose response curve. Finally, we confirmed that the stability can be extended to samples shipped overnight to the laboratory.

Conclusions

It is possible to extend the stability of the basophil activation assay to 1 day for samples stored at 18–25°C as well as samples shipped under ambient conditions as long as the temperature is within the 2–37°C range.

Standardization of nuclear morphometry-based biomarkers

Nuclear morphometry is used to address subtleties of carcinogenesis; it has been proposed for evaluating chemoprevention. An important issue for morphometry concerns control for extraneous sources of variation: fixation, slide cutting and staining. A common strategy has been to standardize the morphometric measures. Morphometric variables--such features as mean nuclear size and staining intensity--are often combined into multivariate indices. In this paper, we consider these variables one by one; any index is to a significant degree dependent on the individual indicators. This paper considers the extent to which statistical adjustment adds to the informational utility of individual indicators. We consider 14 features of 934 prostatic nuclei diagnosed by a single pathologist (Rodolfo Montironi) within a region of either normal tissue or high-grade prostatic intraepithelial neoplasia (HGPIN). HGPIN, a precursor to prostate cancer (PC), has been suggested as a target for PC chemoprevention. We consider a range of adjustment methods: transforming variables into deviations from means or from expected values generated by regression analysis. Our major test of standardization utility is the ability of the variables to deemphasize interindividual differences within diagnostic categories but to distinguish between diagnostic categories.

Developing a postgraduate program in Indigenous mental health and wellbeing at University of Southern Queensland

OBJECTIVE

The aim of this paper is to explain the development of an innovative postgraduate program in Indigenous Australian Mental Health and Well-Being for non-Indigenous health and allied health practitioners.

METHODS

The historical background is explored, together with details of the approach to, and the management of, the new program.

RESULTS

The establishment of the new program has been achieved and the interest level in the new directions being undertaken has been gauged as very high.

CONCLUSIONS

Judging by the number of enquiries, the enrolments so far achieved and the Department of Education, Science and Training granting of 20 HECS places for the new program, it is clear that the program will be viable and the future development of a Master's in Indigenous Mental Health and Well-Being assured.

The effects of nitrous oxide on behavior and physiological parameters during conscious sedation with a moderate dose of chloral hydrate and hydroxyzine

The purpose of this study was to determine differences in heart rate (HR), blood pressure (BP), peripheral oxygen saturation (pO2), expired CO2 (CO2), and behavior (using two scales) comparing nitrous oxide/oxygen (N2O) with oxygen (O2) alone in 20 children (mean age 45 +/- 5.1 months) sedated with chloral hydrate (CH) and hydroxyzine in a double-blind crossover design. Administration of CH (40 mg/kg) and hydroxyzine (2 mg/kg) was held constant for each patient visit; however, N2O (50%) was administered during one visit and O2 (100%) at the other in a randomly determined manner. Physiologic and behavioral parameters were collected during eight specific procedural events (e.g., administration of local anesthesia). Data were analyzed with a repeated-measures ANOVA, one-way ANOVA, t-test, Kruskal Wallis ANOVA, and descriptive statistics. There was no statistically significant difference in any physiologic or behavioral parameter as a function of inhalation agent. However, significant differences were found for certain physiological parameters (i.e., HR [F = 5.41, P < 0.001], pO2 [F = 6.04, P < 0.001], and CO2 [F = 2.33, P < 0.027]) and all behavioral measures (% crying [F = 2.82, P < 0.008], % quiet [F = 5.38, P < 0.001], % movement [F = 3.88, P < 0.001], and % struggle [F = 2.83, P < 0.007]) of one scale (Ohio State University Behavioral Rating Scale [OSUBRS]) as a function of procedural events. Although no statistically significant differences were attributable to inhalation agent, evidence suggests that N2O resulted in less crying and struggling and more quiet behaviors than O2. Significant correlations existed between sub-categories of the two behavioral rating scales, suggesting some association between the scales. One may conclude from the results of this study that moderate doses of CH and hydroxyzine in combination with nitrous oxide are not associated with any significant potentiation effects on physiologic parameters compared with the same oral agents with oxygen alone. Certain procedural events (e.g., administration of local anesthesia) do result in patient responses that affect specific behaviors and physiology. Although the effects of N2O may not be statistically significant, generally it produces an attenuation in physiological and behavioral responses as measured under the conditions of this study.

The management of bleeding gastric ulcer: a prospective study

In a prospective study of six years' experience with a haematemesis and melaena unit from 1972 to 1978, there were 98 admissions of patients with bleeding gastric ulcer. There were ten deaths, giving a mortality of 11%. Forty-one patients were treated by emergency surgery with seven deaths, an operative mortality of 17%. All ten deaths occurred in the first four years; there were no deaths during the final two-year period (38 admissions). In retrospective studies at Prince Henry's Hospital, Melbourne, it was found that the mortality for bleeding gastric ulcer was 17% to 18% for the period 1951 to 1970. It is concluded that a prospective system of management with an active policy of early endoscopy and surgery and regular audit of results reduces the mortality from bleeding gastric ulcer.

Mortality trends in the surgical management of chronic peptic ulceration: 25 years' experience

This study is of the results of surgical management of bleeding chronic peptic ulceration at Prince Henry's Hospital, retrospective for the periods 1951 to 1960 and 1961 to 1970 and prospective for 1972 to 1977. During the latter five years all patients were admitted from the community to a haematemesis and melaena unit with a defined policy of management and prospective data recording for computer analysis. There was a continuing improvement in mortality over this 25-year period, especially with duodenal ulcer. No clear distinction could be made between conservative surgery and partial gastrectomy in terms of reduced surgical mortality in duodenal ulcer. Bleeding gastric ulcer remains a difficult problem, with a current surgical mortality of 21%.