Hospitalizations for asthma exacerbation in Chilean children: A multicenter observational study

Background

Asthma hospitalization rates in Chilean children have increased in the last 14 years, but little is known about the factors associated with this.

Effectiveness of drug treatment strategies to prevent asthma exacerbations and increase symptom-free days in asthmatic children: a network meta-analysis

Objective: To determine the effectiveness and safety of current maintenance therapies that include inhaled corticosteroids (ICS), long-acting β-agonists (LABA) and/or leukotriene receptor antagonists (LTRAs) in preventing exacerbations and improving symptoms in pediatric asthma. Methods: A systematic review with network meta-analysis was conducted after a comprehensive search for relevant studies in the PubMed, Cochrane Library, Embase and Clinical Trials databases, up to July 2014. Randomized clinical trials were selected comparing treatment strategies of the Global Initiative for Asthma guidelines. The full-text randomized clinical trials compared maintenance treatments for asthma in children (≤18 years) of ≥4 weeks duration, reporting exacerbations or symptom-free days. The primary and secondary effectiveness outcomes were the rates of moderate/severe exacerbations and symptom-free days from baseline, respectively. Withdrawal rates were taken as the safety outcome. Results: Included in the network meta-analysis was 35 trials, comprising 12?010 patients. For both primary and secondary outcomes, combined ICS and LABA was ranked first in effectiveness (OR 0.70, 95% CI: 0.52–0.97 and OR 1.23, 95% CI: 0.94–1.61, respectively, compared with low-dose ICS), but the result of secondary outcomes was statistically insignificant. Low-dose ICS, medium- or high-dose ICS and combined ICS and LTRA strategies were comparable in effectiveness. ICS monotherapies, and ICS?+?LABA and ICS?+?LTRA strategies were similarly safe. High-dose ICS had the highest rate of total withdrawals, but the difference was not significant. Conclusions: Combined ICS and LABA treatments were most effective in preventing exacerbations among pediatric asthma patients. Medium- or high-dose ICS, combined ICS and LTRAs, and low-dose ICS treatments seem to be equally effective.     

Susceptibility to exacerbations in Black adults with asthma

Objective: Exacerbations account for much of the morbidity in asthma. In a large intervention study, we sought to test the hypothesis that a Black adult exacerbation-prone phenotype – a group of Black people with asthma who are at high risk of repeat exacerbation within one year – exists in asthma independent of clinical control. Methods: We analyzed exacerbation risk factors in 536 self-identified Black Americans with asthma eligible for, or on, Step 3 National Asthma Education and Prevention Program (NAEPP) therapy who participated in a randomized 6–18?month trial of tiotropium versus long acting beta agonist as add-on therapy to inhaled corticosteroids. Exacerbations were defined as events treated by oral or systemic corticosteroids. Clinical control was assessed by a validated asthma control questionnaire (ACQ5). Results: Exacerbations became more likely with loss of clinical control. The mean baseline ACQs for exacerbators and non-exacerbators were 2.41 and 1.91, respectively (p?<?0.001). The strongest independent factor associated with exacerbations across all ACQ levels was an exacerbation in the preceding year (adjusted OR 3.26; p?<?0.001). The severity of prior exacerbations did not correlate with the likelihood of a future exacerbation. Lower baseline FEV1/FVC was also associated with increased risk of exacerbations. Conclusions: Even though exacerbations increase with loss of clinical control, an exacerbation susceptibility phenotype exists in Black adults with asthma, independent of clinical control. This phenotype requires precision therapeutic targeting.     

Burden of asthma among children in a developing megacity: childhood asthma study,Pakistan

Objectives: Global burden of childhood asthma has increased in the past few decades, particularly in low-income countries. In Pakistan, there is a lack of community-based epidemiological studies estimating the burden of asthma among children. This study determined the prevalence and predictors of asthma among children 3–17 years of age in Karachi, Pakistan. Methods: A two-stage community-based representative cross-sectional survey was conducted in Karachi from March 2012 to April 2013 comprising 1046 children aged 3–17 years. Of 7500 clusters, 80 were randomly selected, and of these, 15 children per cluster were enrolled randomly. A translated and pre-tested version of International Study of Asthma and Allergies in Children questionnaire was administered. Results: The overall prevalence of asthma among study participants was 10.2% (95% CI: 8.4–12.0). Asthma was more likely to occur among boys (adj. OR: 2.5, 95% CI: 1.6–4.0), children in the younger age group (3–7 years) (adj. OR: 2.9, 95% CI: 1.7–4.8), those living in households with ill-ventilated kitchens (adj. OR: 1.8, 95% CI: 1.1–3.1), having family history of asthma (adj. OR: 2.3, 95% CI: 1.3–3.9) and those of the Sindhi ethnicity (adj. OR: 2.2, 95% CI: 1.1–4.4). Conclusion: This study is the first robust evidence regarding asthma among children in Pakistan, reporting a high burden in this group. Family history, male gender, Sindhi ethnicity and ill-ventilated kitchen were identified as important predictors of asthma. Targeted preventive measures and intervention studies are required to better understand and reduce the burden of asthma among children in Pakistan.     

Uncontrolled asthma and its risk factors in Chinese children: A cross-sectional observational study

Objective: Asthma afflicts many children in China but information about asthma management among Chinese pediatric asthma patients is limited. This study aims to evaluate asthma control among Chinese pediatric patients and identify risk factors associated with uncontrolled asthma. Methods: A total of 4223 patients with persistent asthma aged 2–16 years from 42 tertiary hospitals across all regions of mainland China except Tibet were surveyed. Asthma Control Test (ACT), Childhood Asthma Control Test (C-ACT) and Global Initiative for Asthma (GINA) criteria were used to assess asthma control for children aged 12–16 years, 4–11 years and 2–3 years, respectively. Uncontrolled asthma was defined as ACT or C-ACT score ≤19 or GINA-defined uncontrolled asthma. Risk factors associated with uncontrolled asthma were identified using multivariate logistic regression models. Results: Asthma was uncontrolled in 19.9% of the subjects. High rates of uncontrolled asthma were found in subjects with treatment non-adherence (44.1%), concomitant allergic rhinitis (AR) (23.3%), disease duration ≥ 1.5 years (22.8%), and first-degree relatives with AR (21.5%). The risk of uncontrolled asthma was much higher in the treatment non-adherence group compared to the complete adherence group (OR = 5.79, p < 0.001). Concomitant AR, disease duration ≥ 1.5 years, and first-degree relatives with AR were also confirmed as risk factors associated with uncontrolled asthma. Conclusions: About 20% of Chinese pediatric asthma patients had uncontrolled asthma. Treatment adherence and AR were the most significant risk factors. Tailored measures aimed at improving treatment adherence and diagnosis and treatment of AR should be adopted to improve the level of asthma control in Chinese children.     

A prospective multicenter study of factors associated with hospital admission among adults with acute asthma

PURPOSE: We sought to determine patient characteristics associated with hospital admission after emergency treatment for asthma, and whether disposition guidelines are followed. SUBJECTS AND METHODS: We performed a prospective multicenter cohort study involving 64 emergency departments in the United States and Canada. Consecutive adult patients with asthma exacerbations were interviewed, and their charts were reviewed using standardized protocols. Telephone follow-up at 2 weeks determined relapse. RESULTS: Of 1805 patients, 363 (20%; 95% confidence interval [CI]: 18% to 22%) were hospitalized. Among patients with severe exacerbations (final peak flow <50% of predicted), 122 (49%; 95% CI: 43% to 55%) were hospitalized. Admission was associated with final peak flow, female sex, nonwhite race, severity of chronic illness, and severity of exacerbation. Admission predictors were similar regardless of hospital funding, region, or size. Among patients with mild or moderate exacerbations of asthma (peak flow >or=50% predicted), the likelihood of admission was associated significantly with the number of predefined risk factors for death from asthma. Of patients who were discharged from the emergency department, 62 (5%; 95% CI: 4% to 6%) relapsed within 72 hours. Relapse was not associated with final peak flow (P = 0.39). CONCLUSION: Associations between patient characteristics and disposition were similar across sites. Despite guidelines to the contrary, half of patients with final peak flow <50% were discharged. After emergency department treatment and discharge, short-term relapse was uncommon among patients with asthma, suggesting that strict peak flow cutoffs may be unnecessary if risk factors in patients with mild or moderate exacerbations are considered.     

Asthma exacerbations and socio-economic status in French adults with persistent asthma: A prospective cohort study

Introduction: Adults disadvantaged by poor socio-economic status (SES) are more severely affected by asthma compared to those with better SES. We aimed to determine whether the frequency of asthma exacerbations (AEx), as well as aspects related to AEx management, differed based on SES in patients treated with daily treatments. Methods: This study, part of the prospective observational cohort ASTRO-LAB, included French adult patients with persistent asthma. Patients were considered as low SES if they benefited from publicly funded special health insurance and/or were perceived as low SES by their general practitioner. AEx was defined as at least one of the following: asthma-related oral corticosteroid course, medical contact, hospitalization, and death. We examined associations between SES and AEx frequency, perceived triggering factors and type of medical contact after AEx. Results: In our sample of 255 patients, 11.40% were considered as low SES. Patients with low SES did not report significantly more AEx than medium/high SES patients during one-year follow-up (0.79 versus 0.55, p = 0.38). The type of medical contact during AEx differed significantly between the two groups (p = 0.03): patients with medium/high SES consulted their general practitioner more frequently (OR = 2.23, 95% CI = 0.91–5.50, p = 0.08) and were less likely to visit an emergency department or be hospitalized (OR = 0.27, 95% CI = 0.09–0.84, p = 0.02). Conclusions: AEx frequency did not differ significantly between low and medium/high SES patients, but differences were found in the management of AEx. Studies are needed to better understand the relation between precariousness and management of asthma.     

重庆地区支气管哮喘加重住院的多中心回顾性分析

目的 通过分析重庆地区支气管哮喘(简称哮喘)加重住院治疗的原因,为今后加强哮喘管理,减少哮喘加重住院提供依据.方法 采用多中心、回顾性研究的方法,分析在2007年1～12月期间重庆市14家医院哮喘患者加重住院的情况.结果 在此期间共有符合入选标准的住院哮喘患者570例,其中女性61.9％,明显多于男性,年龄4～87岁,平均50.19岁,平均住院8.16d,平均住院费用5 711.8元.82.46％(470/570)的患者存在不同的诱因,其中以受凉感冒最多见,占55.26％. 78.77％(449/570)的患者在非急性加重期没有规律用药治疗.仅选择氨茶碱或单纯用β受体激动剂进行治疗的占87.17％.虽有16.3％(93/570)的患者曾用吸人性糖皮质激素(ICS)联合长效β2受体激动剂(LABA)治疗,但仅12.81％(73/570)坚持规律用药.全部患者中仅7.89％ (45/570)患者是难治性哮喘.绝大部分患者预后良好,97.19％好转出院,2.11％(12/570)自动出院,仅0.70％(4/570)死亡.结论 重庆地区大多数哮喘急性加重患者在稳定期没有进行规范的哮喘治疗,这可能是急性加重的重要原因.因此,加强哮喘患者疾病知识宣教、治疗的管理和指导对减少急性加重具有重要意义.     

哮喘对儿童生活质量的影响

支气管哮喘为儿童常见的慢性炎症性疾病，近年来其发病率在各国明显上升，影响了患儿及其家庭的生活质量。本文主要讨论哮喘给患儿家庭带来沉重的经济负担以及对家庭成员的身心健康的影响，疾病导致的缺课以及夜间的睡眠打断对患儿白天的学习表现的不良影响，患儿与同龄儿童相处的影响，以及疾病带来的不同程度体育运动受限和各种心理行为障碍。     

Evaluation of the asthma control test: a reliable determinant of disease stability and a predictor of future exacerbations

Background and objective: This study assessed the asthma control test (ACT) cut‐off values for asthma control according to the Global Initiative for Asthma guideline in adults and the effectiveness of ACT scores in predicting exacerbations and serial changes in ACT scores over time in relation to treatment decisions. Methods: Subjects completed ACT together with same‐day spirometry and fractional concentration of exhaled nitric oxide (FeNO) measurement at baseline and at 3 months. Physicians, blinded to the ACT scores and FeNO values, assessed the patient's asthma control in the past month and adjusted the asthma medications according to management guidelines. Asthma exacerbations and urgent health‐care utilization (HCU) at 6 months were recorded. Results: Three hundred seventy‐nine (120 men) asthmatics completed the study. The ACT cut‐off for uncontrolled and partly controlled asthma were ≤19 (sensitivity 0.74, specificity 0.67, % correctly classified 69.5) and ≤22, respectively (sensitivity 0.73, specificity 0.71, % correctly classified 72.1). Baseline ACT score had an odds ratio of 2.34 (95% confidence interval: 1.48–3.69) and 2.66 (1.70–4.18) for urgent HCU and exacerbations, respectively, at 6 months (P < 0.0001). However, baseline FeNO and spirometry values had no association with urgent HCU and exacerbations. The 3‐month ACT score of ≤20 correlated best with step‐up of asthma medications (sensitivity 0.65, specificity 0.81, % correctly classified 72.8). For serial changes of ACT scores over 3 months, the cut‐off value was best at ≤3 for treatment decisions with low sensitivity (0.23) and % correctly classified (57.3%) values. Conclusions: Single measurement of ACT is useful for assessing asthma control, prediction of exacerbation and changes in treatment decisions.     

Late outcomes after acute pulmonary embolism: rationale and design of FOCUS,a prospective observational multicenter cohort study

Acute pulmonary embolism (PE) is a frequent cause of death and serious disability. The risk of PE-associated mortality and morbidity extends far beyond the acute phase of the disease. In earlier follow-up studies, as many as 30?% of the patients died during a follow-up period of up to 3 years, and up to 50?% of patients continued to complain of dyspnea and/or poor physical performance 6 months to 3 years after the index event. The most feared ‘late sequela’ of PE is chronic thromboembolic pulmonary hypertension (CTEPH), the true incidence of which remains obscure due to the large margin of error in the rates reported by mostly small, single-center studies. Moreover, the functional and hemodynamic changes corresponding to early, possibly reversible stages of CTEPH, have not been systematically investigated. The ongoing Follow-Up after acute pulmonary embolism (FOCUS) study will prospectively enroll and systematically follow, over a 2-year period and with a standardized comprehensive program of clinical, echocardiographic, functional and laboratory testing, a large multicenter prospective cohort of 1000 unselected patients (all-comers) with acute symptomatic PE. FOCUS will possess adequate power to provide answers to relevant remaining questions regarding the patients’ long-term morbidity and mortality, and the temporal pattern of post-PE abnormalities. It will hopefully provide evidence for future guideline recommendations regarding the selection of patients for long-term follow-up after PE, the modalities which this follow-up should include, and the findings that should be interpreted as indicating progressive functional and hemodynamic post-PE impairment, or the development of CTEPH.

     

An international observational prospective study to determine the cost of asthma exacerbations (COAX)

Asthma is a common chronic condition that places substantial burden on patients and healthcare services. Despite the standards of asthma control that international guidelines recommend should be achieved, many patients continue to suffer sub-optimal control of symptoms and experience exacerbations (acute asthma attacks). In addition to being associated with reduced quality of life, asthma exacerbations are a key cost driver in asthma management. Routine clinical practice for the management of asthma exacerbations varies in different healthcare systems, so healthcare providers require local costs to be able to assess the value of therapies that reduce the frequency and severity of exacerbations. This prospective study, conducted in a total of 15 countries, assessed the local cost of asthma exacerbations managed in either primary or secondary care. Healthcare resources used were costed using actual values appropriate to each country in local currency and in Euros. Results are presented for exacerbations managed in primary care in Brazil, Bulgaria, Croatia, Czech Republic, Hungary, Poland, Russia, Slovakia, Slovenia, Spain and Ukraine, and in secondary care in Croatia, Denmark, Ireland, Latvia, Norway, Poland, Russia, Slovakia, Slovenia and Spain. Multiple regression analysis of the 2052 exacerbations included in the economic analysis showed that the cost of exacerbations was significantly affected by country (P<0.0001). Mean costs were significantly higher in secondary care (euro 1349) than primary care (euro 445, P=0.0003). Age was a significant variable (P=0.0002), though the effect showed an interaction with care type (P<0.0001). As severity of exacerbation increased, so did secondary care costs, though primary care costs remained essentially constant. In conclusion, the study showed that asthma exacerbations are costly to manage, suggesting that therapies able to increase asthma control and reduce the frequency or severity of exacerbations may bring economic benefits, as well as improved quality of life.     

Reduced asthma morbidity in endemic areas for helminth infections: a longitudinal ecological study in Brazil

Objective: The aim of this study was to evaluate whether endemic areas for helminth infections in Brazil have lower rates of hospital admission due to asthma and whether reduction in helminth endemicity impacts on asthma morbidity. Methods: This was a country-wide ecological study in Brazil. Government databases were the source of information. A cross-sectional analysis accessed the risk of a municipality having high rates of hospital admissions due to asthma according to its records of hospital admissions due to Schistossoma mansoni or intestinal helminth infections. A longitudinal analysis accessed the effect of prevention of helminth infection on asthma morbidity. Data were adjusted for the rates of hospital admissions due to influenza, pneumonia, diarrhea, per capita income, Gini index, number of physicians, proportion of literate inhabitants, urbanization and hospital beds. Results: Hospitalization rates due to asthma in the age range of 5–24 years were lower in municipalities endemic for S. mansoni [adjusted OR: 0.992, CI: 0.989–0.994] or for intestinal helminth infections [adjusted OR: 0.994, CI: 0.990–0.997]. Similar results were observed for the age range of 25–64 years. In the longitudinal analysis, municipalities that reduced hospitalizations due to S. mansoni had smaller odds to decrease hospital admissions due to asthma among young populations [adjusted OR: 0.43, CI: 0.22–0.82]. Conclusion: We conclude that populations exposed to helminths have lower asthma morbidity. Reduction of helminth infection prevalence in low-income populations was associated with a smaller decline in asthma morbidity.     

Epidemiological and clinical data of hospitalizations associated with respiratory syncytial virus infection in children under 5 years of age in Spain: FIVE multicenter study

Background

Respiratory syncytial virus (RSV) is an important pathogen in lower respiratory tract infections (LRTI) in infants, but there are limited data concerning patients with underlying conditions and children older than 2 years of age.

Methods

We have designed a prospective observational multicenter national study performed in 26 Spanish hospitals (December 2011–March 2012). Investigational cases were defined as children with underlying chronic diseases and were compared with a group of previously healthy children (proportion 1:2). Clinical data were compared between the groups.

Results

A total of 1763 children hospitalized due to RSV infection during the inclusion period were analyzed. Of them, 225 cases and 460 healthy children were enrolled in the study. Underlying diseases observed were respiratory (64%), cardiovascular (25%), and neurologic (12%), as well as chromosomal abnormalities (7·5%), immunodeficiencies (6·7%), and inborn errors of metabolism (3·5%). Cases were statistically older than previously healthy children (average age: 16·3 versus 5·5 months). Cases experienced hypoxemia more frequently (P < 0·001), but patients with respiratory diseases required oxygen therapy more often (OR: 2·99; 95% CI: 1·03–8·65). Mechanical ventilation was used more in patients with cardiac diseases (OR: 3·0; 95% CI: 1·07–8·44) and in those with inborn errors of metabolism (OR: 12·27; 95% CI: 2·11–71·47). This subgroup showed a higher risk of admission to the PICU (OR: 6·7, 95% CI: 1·18–38·04). Diagnosis of pneumonia was more frequently found in cases (18·2% versus 9·3%; P < 0·01).

Conclusions

A significant percentage of children with RSV infection have underlying diseases and the illness severity is higher than in healthy children.     

雾化吸人高剂量糖皮质激素对儿童中重度支气管哮喘急性发作的疗效

目的 观察吸入糖皮质激素(ICS)对儿童中～重度哮喘急性发作的疗效,探讨更有效、安全的儿童哮喘急性发作治疗方案.方法 采用前瞻性、随机、双盲、安慰剂平行对照研究方法,将40例5～15岁(男30例,女10例)因哮喘急性发作急诊的儿童按随机数字表法随机分为吸入激素组(21例)和常规治疗组(19例),分别以氧动雾化吸入法吸人0.5％沙丁胺醇(150 μg/kg)+0.025％溴化异丙托品(1 ml) +0.05％布地奈德(2 ml)或0.5％沙丁胺醇(150 μg/kg) +0.025％溴化异丙托品(1 ml)+生理盐水(2 ml),每30分钟雾化吸人1次,连用3次.治疗前、刚完成3次雾化吸人后(治疗后0h)、完成后1h(治疗后1h)、完成后2h(治疗后2h)分别测定肺通气功能、心率(HR)、呼吸频率(RR)、经皮测SaO2,进行临床计分(CS).结果 吸入激素组和常规治疗组治疗后CS、RR、SaO2、FEV1、FEV1占预计值％(FEV1％)均较治疗前明显改善(均P＜0.05),HR治疗前后比较差异无统计学意义(均P＞0.05).治疗后2 h吸入激素组和常规治疗组CS[中位数(四分位间距)]分别为0(0)分和0(1)分,吸入激素组明显低于常规治疗组(Z =2.522,P=0.012).两组间治疗前后RR、HR和SaO2比较差异均无统计学意义(均P＞0.05).吸人激素组治疗后第1小时和第2小时FEV1占预计值％分别改善8.0％(6.8％)和5.5％(6.5％),常规治疗组分别改善6.0％(8.5％)和1.0％(6.5％),吸入激素组治疗后第2小时FEV1改善0.07(0.12)L,常规治疗组为0.01(0.10)L.两组间比较差异均有统计学意义(Z值分别为2.270、2.686和2.455,均P＜0.05).吸人激素组治疗后2h完全缓解率为85.0％(17/20),明显高于常规治疗组的50.0％ (9/18),差异有统计学意义(x2=5.371, P=0.024).吸入激素组和常规治疗组需要全身用糖皮质激素的比率分别为15.0％( 3/20)和44.4％(8/18),两组间比较差异有统计学意义(x2=3.993,P=0.046).吸入激素组仅5％(1/20)患儿需住院治疗,而常规治疗组17％ (3/18)患儿需住院治疗.结论 中～重度哮喘急性发作时,高剂量、短时间间隔雾化吸入布地奈德能与吸人速效支气管舒张剂发挥协同作用,快速有效缓解哮喘急性发作症状,改善肺功能,减少全身用糖皮质激素使用,降低住院率,在非危及生命哮喘急性发作可替代或部分替代全身用糖皮质激素.     

小儿哮喘病与卡介苗疤痕的相关性研究

目的研究卡介苗疤痕（卡疤）与哮喘的相关性。方法观察200例儿童,年龄6—12岁,其中哮喘患儿100例,正常对照100例,测量卡疤纵横直径,取平均值。结果哮喘患儿中卡疤直径大于5mm者有52例,占52％。正常对照组卡疤直径大于5mm者有72例,占72％,两组相比较,差别有显著性。两组儿童在年龄分布和性别构成上差异无显著性。结论卡疤直径可能是哮喘发作的一个有价值的预报因子。     

Asthma exacerbations in patients with asthma and rhinitis: Factors associated with asthma exacerbation and its effect on QOL in patients with asthma and rhinitis

BackgroundThe comorbidity of asthma and allergic rhinitis is remarkably high, but not much is known about the effects of this combined condition on the quality of life. We aimed to evaluate the factors associated with asthma exacerbations and the effect of the exacerbations on the quality of life (QOL) through a one-year, large-scale, observational study in Japanese patients with asthma and rhinitis.MethodsA case survey by attending physicians and a patient survey was conducted at each assessment timepoint over a period of one year. Patients were divided into two groups according to the presence or absence of asthmatic attacks after enrollment and were matched using propensity scores to evaluate the factors associated with asthma exacerbations and the effect of the exacerbation on QOL.ResultsPotential factors associated with asthma exacerbations included high body mass index value, low forced expiratory flow 75% of forced vital capacity (FEF75%), severe rhinitis as determined based on ARIA (Allergic Rhinitis and its Impact on Asthma). Although patients with asthma exacerbations had significantly impaired quality of life at baseline as evidenced by the economic aspects, in addition to physical, mental, and social activities, no further reduction with the attacks was observed.ConclusionsThis study suggested that higher body mass index (BMI) and severe asthma as well as severe rhinitis were factors associated with asthma exacerbations. Although patients with asthma exacerbations had impaired QOL, attacks caused no further reduction.