Heather Hoch

Can we predict fall asthma exacerbations? Validation of the seasonal asthma exacerbation index

Background: A Seasonal Asthma Exacerbation Predictive Index (saEPI) was previously reported based on 2 prior National Institute of Allergy and Infectious Diseases Inner City Asthma Consortium trials. Objective: This study sought to validate the saEPI in a separate trial designed to prevent fall exacerbations with omalizumab therapy. Methods: The saEPI and its components were analyzed to characterize those who had an asthma exacerbation during the Preventative Omalizumab or Step‐Up Therapy for Fall Exacerbations (PROSE) study. We characterized those inner‐city children with and without asthma exacerbations in the fall period treated with guidelines‐based therapy (GBT) in the absence and presence of omalizumab. Results: A higher saEPI was associated with an exacerbation in both the GBT alone (P < .001; area under the curve, 0.76) and the GBT + omalizumab group (P < .01; area under the curve, 0.65). In the GBT group, younger age at recruitment, higher total IgE, higher blood eosinophil percentage and number, and higher treatment step were associated with those who had an exacerbation compared with those who did not. In the GBT + omalizumab group, younger age at recruitment, increased eosinophil number, recent exacerbation, and higher treatment step were also associated with those who had an exacerbation. The saEPI was associated with a high negative predictive value in both groups. Conclusions: An exacerbation in children treated with GBT with or without omalizumab was associated with a higher saEPI along with higher markers of allergic inflammation, treatment step, and a recent exacerbation. Those that exacerbated on omalizumab had similar features with the exception of some markers of allergic sensitization, indicating a need to develop better markers to predict poor response to omalizumab therapy and alternative treatment strategies for children with these risk factors. The saEPI was able to reliably predict those children unlikely to have an asthma exacerbation in both groups.

Intermittent steroid inhalation for the treatment of childhood asthma.

Inhaled corticosteroids have long been considered a mainstay of therapy for asthma in children. However, concerns over long-term side effects of chronic steroid administration have led providers to turn to intermittent dosing of these medications in an attempt to treat exacerbations while limiting total corticosteroid received. The data have been somewhat mixed in this area, likely at least partially due to the difficulty providers have in classifying asthma phenotypes in young children. This review will analyze the evidence for chronic daily inhaled corticosteroid use, intermittent inhaled corticosteroid use, and dynamic dosing approaches utilizing inhaled corticosteroid/long-acting beta agonist combination therapy.

Consumer Empowerment in Dermatology

Health care consumers increasingly confront and collaborate with medical providers. This article describes recent developments in health care consumer activism including dermatology disease advocacy and efforts to improve dermatologist-patient interactions.

Modern Molecular Therapies for Application in Managing Childhood Asthma

Abstract Focus on drug development for asthma has been on development of immunomodulator therapies, with the hopes that they can eventually alter the natural course of asthma. This review focuses on the currently available immunomodulating therapies for children. Allergen immunotherapy has been long used as an approach in allergic asthma in children and has the potential ability to alter the natural course of asthma over time. Omalizumab, a humanized anti-IgE specific form of IgG, is the best studied of a new crop of antiallergic mediator immunotherapy. Other, newer modalities, such as anti-IL-5 (mepolizumab, reslizumab, and benralizumab) and combined anti-IL 4/13 (dupilumab), have additionally shown promise; however, these have not been extensively studied in children. We will review mechanism of action, pharmacology, and current literature regarding efficacy of these new therapies for childhood asthma. It is our hope that, with future studies, one or more of these agents may be helpful in altering the onset and progression of severe asthma in children.

Chapter 12 – Predicting and Preventing Asthma Exacerbations

Asthma exacerbations are a major component of the personal risk and societal burden of asthma. Key to personalizing asthma care is the prediction and prevention of asthma exacerbations in at-risk individuals. Key predictors of asthma exacerbations include recent exacerbations, low lung function, poor asthma control, and relevant biomarkers. Important factors in the prevention of asthma exacerbations include adequate adherence to inhaled corticosteroid controller therapy, early and appropriate exacerbation treatment, and biologic therapy if indicated. There remains a need for improvement in exacerbation prediction and prevention to reduce persistently high exacerbation rates. There is much to be gained by implementing personalized care via effective, systematic, and sustainable programs.

Clinical outcomes in U.S. infants with cystic fibrosis from 2001 to 2012

All 50 United States implemented newborn screening (NBS) for cystic fibrosis (CF) by 2010. The purpose of this study was to evaluate trends over the decade when NBS became universal to determine current rates of malnutrition, stunting, and infection rates in U.S. infants with CF.

Feasibility of medication monitoring sensors in high risk asthmatic children

Daily controller therapy is a mainstay of asthma treatment (1), however adherence to asthma medications is problematic (2). Traditionalmethods ofmeasuring adherence do not provide day-to-day objective data. Adherence monitoring sensors that are placed directly on inhaled asthma medications attempt to address this problem (3); however it is unknown how feasible it is to integrate such devices among high-risk, asthmatic children and more evidence is needed on how to integrate these types of devices into real-life clinical practice (4). Our primary objective was to evaluate the feasibility of using a commercially available adherence device in children in a real-life clinical setting. We hypothesized that patients, parents and providers would find the devices easy to use and would continue using them if given the opportunity.

Retrospectoscope: Are the peripheral airways in infants and young children disproportionately small, putting them at risk for severe respiratory illnesses?

The physiology and postnatal growth of the small non-cartilaginous airways (small bronchioles) in infants have interested researchers and clinicians for decades due to the high percentage of infants presenting with wheeze (with or without respiratory failure) during common respiratory illnesses. Hospitalization rates associated with RSV infections are dramatically higher in the first year of life compared to subsequent years and are higher in the first 6 months compared to the latter 6 months of the first year of life. Despite advances in clinical care, morbidity and mortality for RSV in the first year of life remain considerable. What accounts for these high rates? Are there anatomic and physiologic explanations in the peripheral airways? In the 1960s and 1970s, pulmonology emerged as a subspecialty in pediatrics. A prevailing dogma of that early era was that the lungs of infants had significant anatomic and physiologic disadvantages in the

Daily pattern of ß2-agonists: understanding real-life use of rescue medication

Background: The 2009 American Thoracic Society/European Respiratory Society report on asthma control states that s2-agonist use should be presented as “occasion” rather than “puffs” per day (AJRCCM 2009;180:59). Aim: To report the pattern of s2-agonist use after the initial “occasion” defined as the first 2 minutes and further use for the next 4 hours. Methods: s2-agonist use was determined with an electronic sensor recording date, time and number of puffs. Data were collected at the initial “occasion” and at 10, 60, 120 and 240 minutes after the initial “occasion.” Results: Data were recorded for 3,373 patients (mean age: 31) from 3/2015 to 2/2017. Patients used s2-agonists on 56,487 days. At the initial “occasion” 30%, 53%, 9%, 4% and 4% used 1, 2, 3, 4 or ≥ 5puffs, respectively, for a total of 117,450 puffs. The percent of puffs/time period following initial “occasion” stayed consistent over 4 hours as puffs subsequently increased by 21% to 141,586. Figure presents percent of puffs used by time. Conclusion: Analysis by “occasion” does not fully reveal the variability of s2-agonist use. Over the 5 time periods studied, 50% of subjects used 2 puffs, and the other 50% used 1 or ≥3 puffs. Differing patterns may reflect variable need, instruction or habit. Use of digital health tools show that puffs/day is a more reliable assessment of s2-agonist use compared to “occasion” to determine need for rescue or adherence to instructions.