ABSTRACT
Background: Social distancing early in the COVID-19 pandemic helped mitigate viral spread and protect vulnerable populations. Broad availability of vaccines allowed social re-integration, but effects on mental health, social determinants of health, and attitudes among individuals with COPD, who are high-risk for adverse outcomes following COVID-19 infection, are unknown. Methods: Participants in the Losartan Effects on Emphysema Progression (LEEP) trial were recruited into an ancillary study from May-November 2020. Study coordinators administered telephone questionnaires to evaluate respiratory symptoms (COPD Assessment Test [CAT]), anxiety (Generalized Anxiety Disorder-7 [GAD-7]) and depressive (Patient Health Questionnaire [PHQ-8]) symptoms, social isolation, instrumental support, and attitudes and actions related to the COVID-19 pandemic. Generalized estimating equation models evaluated changes in patient-reported scores from the period before vaccine availability (pre-vaccine, May-December 2020) to the post-vaccine period (May 2021-September 2022). Results: Of 157 enrolled participants, 138 were interviewed during both periods. Compared with the pre-vaccine period, severe respiratory symptoms (CAT>20) were higher in the post-vaccine period (odds ratio [OR] 1.36, 95% confidence interval [95%CI]: 1.00-1.85), as were moderate anxiety symptoms (GAD-7≥10; OR 1.65, 95%CI: 1.11-2.46) and moderate depressive symptoms (PHQ-8≥10; OR 1.77, 95%CI: 1.22-2.55). Social isolation improved, though not significantly, and instrumental support was unchanged. In the post-vaccine period compliance with COVID-19 mitigation strategies remained high and governmental healthcare entities were viewed as trustworthy by fewer respondents. Conclusion: Despite a trend towards less social isolation following broad availability of COVID-19 vaccines, individuals with COPD reported worse symptoms, and greater anxiety and depressive symptoms compared to the pre-vaccine period.
ABSTRACT
PURPOSE: Telemedicine Critical Care (TCC) improves adherence to evidence based protocols associated with improved mortality among patients receiving invasive mechanical ventilation (IMV). We sought to evaluate the relationship between hospital availability of TCC and outcomes among patients receiving IMV. MATERIALS AND METHODS: We performed a cross-sectional study of 66,522 adults who received IMV for non-postoperative acute respiratory failure at 318 non-federal hospitals in New York, Massachusetts, Maryland, and Florida in 2018. Hospital-level TCC availability was ascertained from the 2018 American Hospital Association Annual Survey. The primary outcome was in-hospital mortality. Secondary outcomes included the composite of tracheostomy or reintubation and duration of IMV. We used two-level hierarchical multivariable regression models to investigate the association between TCC availability and outcomes. RESULTS: 20,270 (30.5%) patients were admitted into 89 TCC-available hospitals. There was no difference between TCC and non-TCC-available hospitals in mortality (odds ratio [OR] 0.94, 99% confidence interval [CI] 0.84-1.05), composite of tracheostomy or reintubation (OR 0.95 [0.82-1.11], or duration of IMV (OR 0.95 [0.83-1.09]). There was no difference in outcomes among the subgroup of patients with acute respiratory distress syndrome. CONCLUSIONS: Hospital TCC availability was not associated with improved outcomes among patients receiving IMV.
Subject(s)
Critical Care , Hospital Mortality , Respiration, Artificial , Telemedicine , Humans , Respiration, Artificial/statistics & numerical data , Female , Male , Cross-Sectional Studies , Middle Aged , Telemedicine/statistics & numerical data , Critical Care/statistics & numerical data , Aged , Tracheostomy/statistics & numerical data , Respiratory Insufficiency/therapy , Respiratory Insufficiency/mortality , United States , Health Services Accessibility , Adult , Intensive Care Units/statistics & numerical dataABSTRACT
The Global Initiative for Asthma (GINA) recommends that short-acting ß2-agonist (SABA) monotherapy should no longer be prescribed, and that as-needed combination inhaled corticosteroids (ICS)-formoterol is the preferred reliever therapy in adults and adolescents with mild asthma. These recommendations are based on the risks of SABA monotherapy, the evidence that ICS-formoterol reliever therapy markedly decreases the occurrence of severe asthma exacerbations compared with SABA reliever therapy alone, and because ICS-formoterol reliever therapy has a favorable risk/benefit profile compared with maintenance ICS plus SABA reliever therapy. Data supporting the use of combination ICS-albuterol reliever therapy in mild asthma are more limited, but there are studies that inform its use in this population. In this review, we compare, using a pros and cons format, the (1) long-term safety and efficacy of ICS-formoterol reliever therapy versus SABA reliever therapy alone, (2) long-term safety and efficacy of ICS-albuterol reliever therapy versus SABA reliever therapy alone, (3) immediate bronchodilator effects of ICS-formoterol versus SABA alone, and (4) clinical and regulatory factors that may inform reliever therapy prescription decisions. By presenting the evidence of these reliever inhaler options, we hope to inform the reader while also calling for necessary future effectiveness and implementation research.
Subject(s)
Anti-Asthmatic Agents , Asthma , Adult , Adolescent , Humans , Anti-Asthmatic Agents/therapeutic use , Asthma/drug therapy , Asthma/epidemiology , Bronchodilator Agents/therapeutic use , Adrenal Cortex Hormones/therapeutic use , Formoterol Fumarate/therapeutic use , Albuterol/therapeutic use , Administration, Inhalation , Budesonide/therapeutic use , Ethanolamines/therapeutic useABSTRACT
BACKGROUND: Bronchial thermoplasty (BT) is a treatment for patients with poorly controlled, severe asthma. However, predictors of treatment response to BT are defined poorly. RESEARCH QUESTION: Do baseline radiographic and clinical characteristics exist that predict response to BT? STUDY DESIGN AND METHODS: We conducted a longitudinal prospective cohort study of participants with severe asthma receiving BT across eight academic medical centers. Participants received three separate BT treatments and were monitored at 3-month intervals for 1 year after BT. Similar to prior studies, a positive response to BT was defined as either improvement in Asthma Control Test results of ≥ 3 or Asthma Quality of Life Questionnaire of ≥ 0.5. Regression analyses were used to evaluate the association between pretreatment clinical and quantitative CT scan measures with subsequent BT response. RESULTS: From 2006 through 2017, 88 participants received BT, with 70 participants (79.5%) identified as responders by Asthma Control Test or Asthma Quality of Life Questionnaire criteria. Responders were less likely to undergo an asthma-related ICU admission in the prior year (3% vs 25%; P = .01). On baseline quantitative CT imaging, BT responders showed less air trapping percentage (OR, 0.90; 95% CI, 0.82-0.99; P = .03), a greater Jacobian determinant (OR, 1.49; 95% CI, 1.05-2.11), greater SD of the Jacobian determinant (OR, 1.84; 95% CI, 1.04-3.26), and greater anisotropic deformation index (OR, 3.06; 95% CI, 1.06-8.86). INTERPRETATION: To our knowledge, this is the largest study to evaluate baseline quantitative CT imaging and clinical characteristics associated with BT response. Our results show that preservation of normal lung expansion, indicated by less air trapping, a greater magnitude of isotropic expansion, and greater within-lung spatial variation on quantitative CT imaging, were predictors of future BT response. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01185275; URL: www. CLINICALTRIALS: gov.
Subject(s)
Asthma , Bronchial Thermoplasty , Humans , Asthma/drug therapy , Bronchial Thermoplasty/adverse effects , Bronchial Thermoplasty/methods , Longitudinal Studies , Prospective Studies , Quality of Life , Tomography, X-Ray ComputedABSTRACT
BACKGROUND: The Global Initiative for Asthma and National Asthma Education and Prevention Program recently made paradigm-shifting recommendations regarding inhaler management in asthma. The Global Initiative for Asthma now recommends that combination inhaled corticosteroid (ICS)-formoterol inhalers replace short-acting ß-agonists as the preferred reliever therapy at all steps of asthma management. Although the most recent guidelines of the National Asthma Education and Prevention Program did not review reliever ICS-formoterol usage in mild asthma, they similarly recommended single maintenance and reliever therapy (SMART) at steps 3 and 4 of asthma management. Despite these recommendations, many clinicians-particularly in the United States-are not prescribing new inhaler paradigms. Clinician-level reasons for this implementation gap remain largely unexplored. OBJECTIVE: To gain an in-depth understanding of the facilitators and barriers to prescribing reliever ICS-formoterol inhalers and SMART in the United States. METHODS: Community and academic primary care providers, pulmonologists, and allergists who reported regularly caring for adults with asthma were interviewed. Interviews were recorded, transcribed, qualitatively coded, and analyzed using the Consolidated Framework for Implementation Research. Interviews were continued until theme saturation. RESULTS: Among 20 interviewed clinicians, only 6 clinicians described regularly prescribing ICS-formoterol inhalers as a reliever inhaler (either alone or within SMART). Significant barriers to new inhaler approaches included concerns surrounding a lack of Food and Drug Administration labeling for ICS-formoterol as a reliever therapy, a lack of awareness regarding a patient's formulary-preferred ICS-long-acting ß-agonist choices, the high cost of combination inhalers, and time constraints. Facilitators to using new inhaler approaches included clinicians' beliefs that the latest inhaler recommendations are simpler and more congruent with real-world patients' behavior, and that a potential change in management strategy would offer a valuable opportunity for shared decision making. CONCLUSIONS: Although new guidelines exist in asthma, many clinicians described significant barriers to using them including medicolegal issues, pharmaceutical formulary confusion, and high drug costs. Nonetheless, most clinicians believed that the latest inhaler approaches would be more intuitive for their patients and would offer an opportunity for patient-centered collaboration and care. Stakeholders may find these results useful in future attempts to increase the real-world adoption of recent asthma recommendations.
Subject(s)
Anti-Asthmatic Agents , Asthma , Adult , Humans , United States/epidemiology , Budesonide/therapeutic use , Anti-Asthmatic Agents/therapeutic use , Ethanolamines/therapeutic use , Administration, Inhalation , Asthma/drug therapy , Budesonide, Formoterol Fumarate Drug Combination/therapeutic use , Formoterol Fumarate/therapeutic use , Nebulizers and Vaporizers , Adrenal Cortex Hormones/therapeutic use , Drug CombinationsSubject(s)
Anti-Asthmatic Agents , Asthma , Humans , United States , Formoterol Fumarate/therapeutic use , Asthma/drug therapy , Bronchodilator Agents/therapeutic use , Adrenal Cortex Hormones/therapeutic use , Nebulizers and Vaporizers , Budesonide/therapeutic use , Ethanolamines/therapeutic use , Administration, Inhalation , Drug Combinations , Anti-Asthmatic Agents/therapeutic useABSTRACT
Asthma researchers have long recognized that abnormal mucus production and clearance play a role in the pathophysiology of asthma.1 Mucus plugs are known to be common in patients with severe asthma, and mucus plug scores, for which higher scores indicate more severe plugging, are directly correlated with airflow obstruction and markers of eosinophilic airway inflammation (i.e., higher scores or marker levels are associated with more severe obstruction). Other work has shown that mucus plugs were associated with distal deficits in regional ventilation as delineated by hyperpolarized gas magnetic resonance imaging.2,3.
Subject(s)
Airway Obstruction , Asthma , Eosinophilia , Humans , Airway Obstruction/complications , Mucus/physiology , Asthma/complications , Lung/pathology , Eosinophilia/complications , Biological TherapyABSTRACT
BACKGROUND: While inhaled corticosteroids (ICS) are considered the essential foundation of most asthma therapy, ICS inhaler nonadherence is a notoriously common problem and a significant cause of asthma-related morbidity. Partially acknowledging the problem of nonadherence, international organizations recently made paradigm-shifting recommendations that all patients with mild-to-moderate persistent asthma be considered for symptom-driven ICS-containing inhalers rather than relying on adherence to traditional maintenance ICS inhalers and symptom-driven short-acting beta-agonists (SABA). With this new approach, asthma patients are at least exposed to the important anti-inflammatory effects of ICS-containing inhalers when their symptom reliever inhaler is deployed due to acute symptoms. METHODS: This study will (Part 1) complete a pragmatic randomized controlled trial to evaluate if an inhaler strategy that utilizes symptom-driven ICS inhalers is particularly beneficial in maintenance ICS inhaler non-adherent asthma patients, and (Part 2) use a dissemination and implementation (D&I) science conceptual framework to better understand patients' and providers' views of inhaler nonadherence. This study, which will have an option of taking place entirely remotely, will use a Food and Drug Administration (FDA)-approved electronic sensor (Hailie® sensor) to monitor inhaler adherence and includes semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR). DISCUSSION: This study is assessing the problem of nonadherence using a D&I implementation science research lens while testing a new inhaler approach to potentially ameliorate the detrimental consequences of maintenance inhaler nonadherence. We hypothesize that the use of a symptom-driven ICS/LABA management strategy, as compared to traditional maintenance ICS treatment and symptom-driven SABA, will lead to improved adherence to an asthma treatment strategy, decreased asthma-related morbidity, less cumulative ICS exposure, and greater patient satisfaction with an inhaler approach. TRIAL REGISTRATION: ClinicalTrials.gov NCT05111262. Registered on November 8, 2021.
Subject(s)
Anti-Asthmatic Agents , Asthma , Adult , Humans , Administration, Inhalation , Adrenal Cortex Hormones/adverse effects , Anti-Asthmatic Agents/adverse effects , Asthma/diagnosis , Asthma/drug therapy , Nebulizers and Vaporizers , Randomized Controlled Trials as TopicABSTRACT
INTRODUCTION: Despite evidence suggesting that point-of-care ultrasound (POCUS) is faster and non-inferior for confirming position and excluding pneumothorax after central venous catheter (CVC) placement compared to traditional radiography, millions of chest radiographs (CXR) are performed annually for this purpose. Whether the use of POCUS results in cost savings compared to CXR is less clear but could represent a relative advantage in implementation efforts. Our objective in this study was to evaluate the labor cost difference for POCUS-guided vs CXR-guided CVC position confirmation practices. METHODS: We developed a model to evaluate the per patient difference in labor cost between POCUS-guided vs CXR-guided CVC confirmation at our local urban, tertiary academic institution. We used internal cost data from our institution to populate the variables in our model. RESULTS: The estimated labor cost per patient was $18.48 using CXR compared to $14.66 for POCUS, resulting in a net direct cost savings of $3.82 (21%) per patient using POCUS for CVC confirmation. CONCLUSION: In this study comparing the labor costs of two approaches for CVC confirmation, the more efficient alternative (POCUS-guided) is not more expensive than traditional CXR. Performing an economic analysis framed in terms of labor costs and work efficiency may influence stakeholders and facilitate earlier adoption of POCUS for CVC confirmation.
Subject(s)
Catheterization, Central Venous , Central Venous Catheters , Catheterization, Central Venous/methods , Cost-Benefit Analysis , Critical Illness , Humans , Prospective Studies , Radiography , Radiography, Thoracic , Ultrasonography, InterventionalABSTRACT
Background Clustering key clinical characteristics of participants in the Severe Asthma Research Program (SARP), a large, multicenter prospective observational study of patients with asthma and healthy controls, has led to the identification of novel asthma phenotypes. Purpose To determine whether quantitative CT (qCT) could help distinguish between clinical asthma phenotypes. Materials and Methods A retrospective cross-sectional analysis was conducted with the use of qCT images (maximal bronchodilation at total lung capacity [TLC], or inspiration, and functional residual capacity [FRC], or expiration) from the cluster phenotypes of SARP participants (cluster 1: minimal disease; cluster 2: mild, reversible; cluster 3: obese asthma; cluster 4: severe, reversible; cluster 5: severe, irreversible) enrolled between September 2001 and December 2015. Airway morphometry was performed along standard paths (RB1, RB4, RB10, LB1, and LB10). Corresponding voxels from TLC and FRC images were mapped with use of deformable image registration to characterize disease probability maps (DPMs) of functional small airway disease (fSAD), voxel-level volume changes (Jacobian), and isotropy (anisotropic deformation index [ADI]). The association between cluster assignment and qCT measures was evaluated using linear mixed models. Results A total of 455 participants were evaluated with cluster assignments and CT (mean age ± SD, 42.1 years ± 14.7; 270 women). Airway morphometry had limited ability to help discern between clusters. DPM fSAD was highest in cluster 5 (cluster 1 in SARP III: 19.0% ± 20.6; cluster 2: 18.9% ± 13.3; cluster 3: 24.9% ± 13.1; cluster 4: 24.1% ± 8.4; cluster 5: 38.8% ± 14.4; P < .001). Lower whole-lung Jacobian and ADI values were associated with greater cluster severity. Compared to cluster 1, cluster 5 lung expansion was 31% smaller (Jacobian in SARP III cohort: 2.31 ± 0.6 vs 1.61 ± 0.3, respectively, P < .001) and 34% more isotropic (ADI in SARP III cohort: 0.40 ± 0.1 vs 0.61 ± 0.2, P < .001). Within-lung Jacobian and ADI SDs decreased as severity worsened (Jacobian SD in SARP III cohort: 0.90 ± 0.4 for cluster 1; 0.79 ± 0.3 for cluster 2; 0.62 ± 0.2 for cluster 3; 0.63 ± 0.2 for cluster 4; and 0.41 ± 0.2 for cluster 5; P < .001). Conclusion Quantitative CT assessments of the degree and intraindividual regional variability of lung expansion distinguished between well-established clinical phenotypes among participants with asthma from the Severe Asthma Research Program study. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Verschakelen in this issue.
Subject(s)
Asthma , Asthma/diagnostic imaging , Cross-Sectional Studies , Female , Humans , Lung/diagnostic imaging , Phenotype , Pulmonary Disease, Chronic Obstructive , Retrospective Studies , Tomography, X-Ray Computed/methodsABSTRACT
Quantitative imaging of the lung has proved to be a valuable tool that has improved our understanding of asthma. CT, MRI, and positron emission tomography have all been utilized in asthma with each modality having its own distinct advantages and disadvantages. Research has now demonstrated that quantitative imaging plays a valuable role in characterizing asthma phenotypes and endotypes, as well as potentially predicting future asthma morbidity. Nonetheless, future research is needed in order to minimize radiation exposure, standardize reporting, and further delineate how imaging can predict longitudinal outcomes. With future work, quantitative imaging may make its way into the clinical care of asthma and change our practice.
Subject(s)
Asthma , Tomography, X-Ray Computed , Asthma/diagnostic imaging , Humans , Lung/diagnostic imaging , Magnetic Resonance Imaging/methods , Positron-Emission TomographyABSTRACT
BACKGROUND: Currently, there is limited knowledge regarding which imaging assessments of asthma are associated with accelerated longitudinal decline in lung function. OBJECTIVES: We aimed to assess whether quantitative computed tomography (qCT) metrics are associated with longitudinal decline in lung function and morbidity in asthma. METHODS: We analyzed 205 qCT scans of adult patients with asthma and calculated baseline markers of airway remodeling, lung density, and pointwise regional change in lung volume (Jacobian measures) for each participant. Using multivariable regression models, we then assessed the association of qCT measurements with the outcomes of future change in lung function, future exacerbation rate, and changes in validated measurements of morbidity. RESULTS: Greater baseline wall area percent (ß = -0.15 [95% CI = -0.26 to -0.05]; P < .01), hyperinflation percent (ß = -0.25 [95% CI = -0.41 to -0.09]; P < .01), and Jacobian gradient measurements (cranial-caudal ß = 10.64 [95% CI = 3.79-17.49]; P < .01; posterior-anterior ß = -9.14, [95% CI = -15.49 to -2.78]; P < .01) were associated with more severe future lung function decline. Additionally, greater wall area percent (rate ratio = 1.06 [95% CI = 1.01-1.10]; P = .02) and air trapping percent (rate ratio =1.01 [95% CI = 1.00-1.02]; P = .03), as well as lower decline in the Jacobian determinant mean (rate ratio = 0.58 [95% CI = 0.41-0.82]; P < .01) and Jacobian determinant standard deviation (rate ratio = 0.52 [95% CI = 0.32-0.85]; P = .01), were associated with a greater rate of future exacerbations. However, imaging metrics were not associated with clinically meaningful changes in scores on validated asthma morbidity questionnaires. CONCLUSIONS: Baseline qCT measures of more severe airway remodeling, more small airway disease and hyperinflation, and less pointwise regional change in lung volumes were associated with future lung function decline and asthma exacerbations.
Subject(s)
Asthma/diagnostic imaging , Lung/diagnostic imaging , Adult , Airway Remodeling , Asthma/pathology , Asthma/physiopathology , Disease Progression , Female , Forced Expiratory Volume , Humans , Lung/pathology , Lung/physiopathology , Male , Middle Aged , Prognosis , Tomography, X-Ray ComputedABSTRACT
BACKGROUND: Patients with asthma are comparatively susceptible to respiratory viral infections and more likely to develop severe symptoms than people without asthma. During the coronavirus disease 2019 (COVID-19) pandemic, it is necessary to adequately evaluate the characteristics and outcomes of the population with asthma in the population tested for and diagnosed as having COVID-19. OBJECTIVE: To perform a study to assess the impact of asthma on COVID-19 diagnosis, presenting symptoms, disease severity, and cytokine profiles. METHODS: This was an analysis of a prospectively collected cohort of patients suspected of having COVID-19 who presented for COVID-19 testing at a tertiary medical center in Missouri between March 2020 and September 2020. We classified and analyzed patients according to their pre-existing asthma diagnosis and subsequent COVID-19 testing results. RESULTS: Patients suspected of having COVID-19 (N = 435) were enrolled in this study. The proportions of patients testing positive for COVID-19 were 69.2% and 81.9% in the groups with asthma and without asthma, respectively. The frequencies of relevant symptoms were similar between the groups with asthma with positive and negative COVID-19 test results. In the population diagnosed as having COVID-19 (n = 343), asthma was not associated with several indicators of COVID-19 severity, including hospitalization, admission to an intensive care unit, mechanical ventilation, death due to COVID-19, and in-hospital mortality after multivariate adjustment. Patients with COVID-19 with asthma exhibited significantly lower levels of plasma interleukin-8 than patients without asthma (adjusted P = .02). CONCLUSION: The population with asthma is facing a challenge in preliminary COVID-19 evaluation owing to an overlap in the symptoms of COVID-19 and asthma. However, asthma does not increase the risk of COVID-19 severity if infected.
Subject(s)
Asthma/complications , COVID-19/diagnosis , COVID-19/epidemiology , Coinfection/epidemiology , Adult , COVID-19/pathology , Coinfection/diagnosis , Coinfection/pathology , Cytokines/blood , Disease Susceptibility/pathology , Female , Humans , Male , Middle Aged , Prospective Studies , SARS-CoV-2 , Severity of Illness Index , Treatment OutcomeABSTRACT
Patients with uncontrolled severe persistent asthma have greater morbidity, greater use of health care resources, and more impairment in health-related quality of life when compared with their peers with well-controlled disease. Fortunately, since the introduction of biological therapeutics, patients with severe eosinophilic asthma now have beneficial treatment options that they did not have just a few years ago. In addition to anti-IgE therapy for allergic asthma, 3 new biological therapeutics targeting IL-5 and 1 targeting IL-4 and IL-13 signaling have recently been approved by the Food and Drug Administration for the treatment of severe eosinophilic asthma, and approval of more biological therapeutics is on the horizon. These medications decrease the frequency of asthma exacerbations, improve lung function, reduce corticosteroid usage, and improve health-related quality of life. This article reviews the mechanisms of action, specific indications, benefits, and side effects of each of the approved biological therapies for asthma. Furthermore, this article reviews how a clinician could use specific patient characteristics to decide which biologic treatment may be optimal for a given patient.
Subject(s)
Anti-Asthmatic Agents/therapeutic use , Asthma/drug therapy , Biological Products/therapeutic use , Eosinophilia/drug therapy , Adrenal Cortex Hormones/therapeutic use , Antibodies, Monoclonal, Humanized/therapeutic use , Asthma/immunology , Asthma/physiopathology , Cytokines/immunology , Disease Progression , Eosinophilia/immunology , Eosinophilia/physiopathology , Humans , Lymphocytes/immunology , Omalizumab/therapeutic use , Severity of Illness Index , Th2 Cells/immunologyABSTRACT
Patients with severe uncontrolled asthma have disproportionally high morbidity and healthcare utilization as compared with their peers with well-controlled disease. Although treatment options for these patients were previously limited, with unacceptable side effects, the emergence of biologic therapies for the treatment of asthma has provided promising targeted therapy for these patients. Biologic therapies target specific inflammatory pathways involved in the pathogenesis of asthma, particularly in patients with an endotype driven by type 2 (T2) inflammation. In addition to anti-IgE therapy that has improved outcomes in allergic asthma for more than a decade, three anti-IL-5 biologics and one anti-IL-4R biologic have recently emerged as promising treatments for T2 asthma. These targeted therapies have been shown to reduce asthma exacerbations, improve lung function, reduce oral corticosteroid use, and improve quality of life in appropriately selected patients. In addition to the currently approved biologic agents, several biologics targeting upstream inflammatory mediators are in clinical trials, with possible approval on the horizon. This article reviews the mechanism of action, indications, expected benefits, and side effects of each of the currently approved biologics for severe uncontrolled asthma and discusses promising therapeutic targets for the future.
Subject(s)
Anti-Asthmatic Agents/therapeutic use , Asthma/drug therapy , Biological Products/therapeutic use , Antibodies, Monoclonal, Humanized/therapeutic use , Humans , Omalizumab/therapeutic useABSTRACT
OBJECTIVE: To explore the feasibility of ecological momentary assessments (EMAs) as a tool to more accurately assess the level of bother from tinnitus. STUDY DESIGN: Longitudinal observational study. SETTING: Washington University Department of Otolaryngology-Head and Neck Surgery faculty practice plan. SUBJECTS AND METHODS: Twenty participants with moderately to severely bothersome tinnitus were enrolled. All participants owned a smartphone device, and all communications were conducted via email, phone, and text messaging. Participants received 4 EMAs per day for 2 weeks via text message and a final survey on the 15th day. In each survey, participants recorded their level of tinnitus bother, their location at the time of response, their stress level, how they were feeling, and what they were doing. Response rates as a proxy for the feasibility of the program. RESULTS: There were a total of 1120 surveys sent to 20 participants (56 surveys per participant), and 889 (79.4%) of the surveys were completed and returned. The median time to response from the moment of receiving the text message was 7 minutes. The distribution of responses to the EMA question, "In the last 5 minutes, how bothered have you been by your tinnitus?" displayed both high between- and within-subject variability. At the end of 2 weeks, the median score on the Tinnitus Handicap Inventory was 37, with a range of 10 to 82 points; the median Tinnitus Functional Index score was 43, with a range of 10 to 82 points. CONCLUSION: This study suggests bothered tinnitus patients will use smartphones as part of EMA.
Subject(s)
Cell Phone , Self Report , Stress, Psychological , Tinnitus/psychology , Adult , Aged , Chronic Disease , Feasibility Studies , Female , Humans , Male , Middle Aged , Pilot ProjectsABSTRACT
OBJECTIVES/HYPOTHESIS: This study aimed to determine the incidence of major complications following both primary and revision transsphenoidal pituitary surgery. Major complications included endocrinopathic, skull base, orbital, hemorrhagic and thromboembolic complications, respiratory failure, and death. Secondarily, this study aimed to examine factors associated with the occurrence of complications. STUDY DESIGN: Retrospective cohort analysis of California and Florida all-payer databases from 2005 to 2008. METHODS: The major complication rate following both primary and revision transsphenoidal pituitary surgery was calculated. Bivariate analyses were performed to investigate the relationship of patient characteristics with complication occurrence, and a multivariate model was constructed to determine risk factors associated with these complications. RESULTS: There were 5,277 primary cases and 192 revision cases that met inclusion criteria. There was a nonsignificant absolute difference of 3.09% (95% confidence interval [CI]: -11.00 to 16.14) between the rate of complications following primary (n = 443, 8.39%) and revision (n = 22, 11.46%) surgeries. Multivariate analyses showed that patients with Medicare (odds ratio [OR]:1.74, 95% CI: 1.17 to 2.61), Medicaid (OR: 2.13, 95% CI: 1.59 to 2.86), or a malignant neoplasm (OR: 3.10, 95% CI: 1.62 to 5.93) were more likely to have complications. CONCLUSIONS: The rate of major complications following transsphenoidal pituitary surgery is lower than earlier retrospective reports. The overall complication rate following revision surgery was not significantly different from primary surgery. Insurance status and a diagnosis of a malignant neoplasm were associated with a higher rate of complications. LEVEL OF EVIDENCE: 2C.