Optimising medication management in children and young people with ADHD using a computerised test (QbTest): a feasibility randomised controlled trial.

BACKGROUND: Medication for attention deficit hyperactivity disorder (ADHD) should be closely monitored to ensure optimisation. There is growing interest in using computerised assessments of ADHD symptoms to support medication monitoring. The aim of this study was to assess the feasibility and acceptability of a randomised controlled trial (RCT) to evaluate the efficacy of one such computerised assessment, the Quantified Behavior (Qb) Test, as part of medication management for ADHD. METHODS: This feasibility multi-site RCT conducted in child and adolescent mental health and community paediatric settings recruited participants aged 6-15 years diagnosed with ADHD starting stimulant medication. Participants were randomised into one of two arms: experimental (QbTest protocol) where participants completed a QbTest at baseline and two follow-up QbTests on medication (2-4 weeks and 8-10 weeks later) and control where participants received treatment as usual, including at least two follow-up consultations. Measures of parent, teacher, and clinician-rated symptoms and global functioning were completed at each time point. Clinicians recorded treatment decision-making and health economic measures were obtained. Data were analysed using multi-level modelling and participants (children and parents) and clinicians were interviewed about their experiences, resulting data were thematically analysed. RESULTS: Forty-four children and young people were randomised. Completion of study outcome measures by care-givers and teachers ranged from 52 to 78% at baseline to 47-65% at follow-up. Participants reported the questionnaires to be useful to complete. SNAP-IV inattention scores showed greater reduction in the intervention than the control group (- 5.85, 95% CI - 10.33, - 1.36,). Engagement with the intervention ranged from 100% at baseline, to 78% follow-up 1 and 57% follow-up 2. However, only 37% of QbTests were conducted in the correct time period. Interview data highlighted that the objectivity of the QbTest was appreciated by clinicians and parents. Clinicians commented that the additional time and resources required meant that it is not feasible to use QbTest for all cases. CONCLUSION: The trial design and protocol appear to be feasible and acceptable but could be improved by modifying QbTest time periods and the method of data collection. With these changes, the protocol may be appropriate for a full trial. Adding QbTest may improve symptom outcome as measured by SNAP-IV. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03368573 , prospectively registered, 11th December 2017, and ISRCTN, ISRCTN69461593 , retrospectively registered, 10th April 2018.

Macrophage Phagocytosis and Allergen Avoidance in Children With Asthma.

Background and Objective: Airway macrophages perform the crucial functions of presenting antigens, clearing pathogens, and apoptotic cells. Macrophage phagocytosis is increased in adults with mild asthma and allergen exposure is known to activate macrophages. However, it is not clear whether the mechanism behind this is due to a primary defect or environmental factors such as allergen or lipopolysaccaride (LPS) exposure. Our aim was to assess the phagocytic function of airway macrophages in children with mild to moderate asthma after residence in a low allergen\LPS environment at high altitude. Methods: Sputum induction was performed in children with asthma at baseline and after residence for a 3 weeks' period at a high-altitude asthma center that has very low ambient allergen levels. The markers of eosinophilic inflammation (including percentage of macrophage cytoplasm with red hue) and phagocytosis of fluorescein isothiocyanate-labeled, heat-killed Staphylococcus aureus by airway macrophages was analyzed. Internalized bacteria were quantified using confocal microscopy. Results: The median bacterial count [mean (standard deviation)] per macrophage was significantly lower [39.55 (4.51) vs. 73.26 (39.42) (p = 0.006)] after residence at high altitude. No association was observed between markers of eosinophilic inflammation and bacterial phagocytosis. Conclusions: The results suggest that the mechanism behind the enhanced phagocytosis of bacteria in childhood asthma may be secondary to allergen or possibly LPS exposure.

Ciliated conical epithelial cell protrusions point towards a diagnosis of primary ciliary dyskinesia.

BACKGROUND: Primary ciliary dyskinesia can result from a number of different ciliary defects that adversely affect ciliary function resulting markedly reduced or absent mucociliary clearance. Improvement in diagnostic testing is an area of current research. During diagnostic evaluation of PCD we observed ciliated conical protrusions from part of the apical surface of ciliated cells in those diagnosed with PCD. The aim of this study was to investigate if this abnormality was specific to PCD. METHODS: Epithelial edges from 67 consecutively diagnosed PCD patients, 67 patients consecutively referred for PCD diagnostic testing in whom PCD was excluded, 22 with asthma and 18 with Cystic Fibrosis (CF) were studied retrospectively in a blinded manner using light microscopy. RESULTS: Forty six out of 67 patients with PCD had ciliated conical epithelial protrusions, whereas none were seen in patients where PCD was excluded, or in patients with asthma or CF. The sensitivity, specificity, positive predictive value and negative predictive value for the presence of the ciliated conical protrusions to predict a diagnosis of PCD were 76.5, 100, 100 and 77% respectively. CONCLUSIONS: Characteristic ciliated conical protrusions from ciliated epithelial cells maybe a useful pointer to the diagnosis of PCD. However, their absence does not exclude the diagnosis of PCD.

Monitoring asthma in childhood: management-related issues.

Management-related issues are an important aspect of monitoring asthma in children in clinical practice. This review summarises the literature on practical aspects of monitoring including adherence to treatment, inhalation technique, ongoing exposure to allergens and irritants, comorbid conditions and side-effects of treatment, as agreed by the European Respiratory Society Task Force on Monitoring Asthma in Childhood. The evidence indicates that it is important to discuss adherence to treatment in a non-confrontational way at every clinic visit, and take into account a patient's illness and medication beliefs. All task force members teach inhalation techniques at least twice when introducing a new inhalation device and then at least annually. Exposure to second-hand tobacco smoke, combustion-derived air pollutants, house dust mites, fungal spores, pollens and pet dander deserve regular attention during follow-up according to most task force members. In addition, allergic rhinitis should be considered as a cause for poor asthma control. Task force members do not screen for gastro-oesophageal reflux and food allergy. Height and weight are generally measured at least annually to identify individuals who are susceptible to adrenal suppression and to calculate body mass index, even though causality between obesity and asthma has not been established. In cases of poor asthma control, before stepping up treatment the above aspects of monitoring deserve closer attention.

Monitoring asthma in children.

The goal of asthma treatment is to obtain clinical control and reduce future risks to the patient. To reach this goal in children with asthma, ongoing monitoring is essential. While all components of asthma, such as symptoms, lung function, bronchial hyperresponsiveness and inflammation, may exist in various combinations in different individuals, to date there is limited evidence on how to integrate these for optimal monitoring of children with asthma. The aims of this ERS Task Force were to describe the current practise and give an overview of the best available evidence on how to monitor children with asthma. 22 clinical and research experts reviewed the literature. A modified Delphi method and four Task Force meetings were used to reach a consensus. This statement summarises the literature on monitoring children with asthma. Available tools for monitoring children with asthma, such as clinical tools, lung function, bronchial responsiveness and inflammatory markers, are described as are the ways in which they may be used in children with asthma. Management-related issues, comorbidities and environmental factors are summarised. Despite considerable interest in monitoring asthma in children, for many aspects of monitoring asthma in children there is a substantial lack of evidence.

COPD exacerbation severity and frequency is associated with impaired macrophage efferocytosis of eosinophils.

BACKGROUND: Eosinophilic airway inflammation is observed in 10-30% of COPD subjects. Whether increased eosinophils or impairment in their clearance by macrophages is associated with the severity and frequency of exacerbations is unknown. METHODS: We categorised 103 COPD subjects into 4 groups determined by the upper limit of normal for their cytoplasmic macrophage red hue (<6%), an indirect measure of macrophage efferocytosis of eosinophils, and area under the curve sputum eosinophil count (≥ 3%/year). Eosinophil efferocytosis by monocyte-derived macrophages was studied in 17 COPD subjects and 8 normal controls. RESULTS: There were no differences in baseline lung function, health status or exacerbation frequency between the groups: A-low red hue, high sputum eosinophils (n=10), B-high red hue, high sputum eosinophils (n=16), C-low red hue, low sputum eosinophils (n=19) and D- high red hue, low sputum eosinophils (n=58). Positive bacterial culture was lower in groups A (10%) and B (6%) compared to C (44%) and D (21%) (p=0.01). The fall in FEV1 from stable to exacerbation was greatest in group A (ΔFEV1 [95 % CI] -0.41 L [-0.65 to -0.17]) versus group B (-0.16 L [-0.32 to -0.011]), C (-0.11 L [-0.23 to -0.002]) and D (-0.16 L [-0.22 to -0.10]; p=0.02). Macrophage efferocytosis of eosinophils was impaired in COPD versus controls (86 [75 to 92]% versus 93 [88 to 96]%; p=0.028); was most marked in group A (71 [70 to 84]%; p=0.0295) and was inversely correlated with exacerbation frequency (r=-0.63; p=0.006). CONCLUSIONS: Macrophage efferocytosis of eosinophils is impaired in COPD and is related to the severity and frequency of COPD exacerbations.

Eosinophilic airway inflammation is increased in children with asthma and food allergies.

BACKGROUND: Asthma is associated with food allergies in a significant number of children, with evidence linking allergies to asthma severity and morbidity. In this study, we tested our hypothesis that the eosinophilic lower airway inflammation is higher in asthmatic children with food allergies. AIMS: The aims of the study were to compare the eosinophilic inflammatory markers in asthmatic children with and without food allergies. MATERIALS AND METHODS: Children with asthma, with (n = 22) and (n = 53) without food allergies were included. All subjects were classified according to the GINA guidelines (2009) and had received at least 3 months of anti-inflammatory therapy prior to testing. Fractional exhaled nitric oxide and sputum differential counts were performed using standard techniques. RESULTS: Children with asthma and food allergies had significantly higher fractional exhaled nitric oxide median (range) [(22.4 (6.1-86.9) vs. 10.3 (2.7-38.7) (p = 0.01)] and sputum eosinophil percentage [15.5 (5.0-53.0) vs. 2.0 (0-20) (p < 0.001)] compared with asthmatic children without allergies. CONCLUSION: These results suggest that the children with asthma and food allergies have increased eosinophilic inflammation of the airways.

Eosinophil protein in airway macrophages: a novel biomarker of eosinophilic inflammation in patients with asthma.

BACKGROUND: Noneosinophilic asthma is common across asthma severities. However, in patients with moderate-to-severe disease, the absence of sputum eosinophilia cannot distinguish between asthmatic subjects with eosinophilic inflammation controlled by corticosteroids versus those in whom eosinophilic inflammation is not a component of the disease. OBJECTIVES: We sought to develop a method to quantify eosinophil proteins in airway macrophages as a novel biomarker of eosinophilic airway inflammation. METHODS: Eosinophil proteins in airway macrophages were assessed by means of flow cytometry, immunofluorescence, and cytoplasmic hue change after ingestion of apoptotic eosinophils. Airway macrophage median percentage of red-hued area in stained sputum cytospin preparations was assessed by means of image analysis from (1) subjects with mild-to-severe asthma, subjects with nonasthmatic eosinophilic bronchitis, and healthy control subjects; (2) subjects with eosinophilic severe asthma after treatment with prednisolone; and (3) subject with noneosinophilic asthma before corticosteroid withdrawal. RESULTS: Eosinophil proteins were detected in airway macrophages, and cytoplasmic red hue increased after ingestion of apoptotic eosinophils. Airway macrophage percentage redhued area was increased in subjects with moderate-to-severe asthma compared with that seen in subjects with mild asthma and healthy control subjects, was similar in those with or without a sputum eosinophilia, and was increased after corticosteroid therapy. In asthmatic subjects without sputum eosinophilia, the airway macrophage percentage red-hued area was increased in subjects who did versus those who did not have sputum eosinophilia after corticosteroid withdrawal. CONCLUSIONS: Eosinophil proteins can be reliably measured in airway macrophages. In combination with sputum eosinophilia, the macrophage eosinophil protein content might further define the asthma phenotype and provide an additional tool to direct therapy.

Domestic smoke exposure is associated with alveolar macrophage particulate load.

OBJECTIVES: Indoor air pollution is associated with impaired respiratory health. The pre-dominant indoor air pollutant to which two billion of the world's population is exposed is biomass fuel smoke. We tested the hypothesis that reported smoke exposure in men and women is associated with increased alveolar macrophage uptake of biomass smoke particulates. METHODS: Healthy volunteers attending for research bronchoscopy in Malawi completed a questionnaire assessment of smoke exposure. Particulate matter visible in alveolar macrophages (AM) was quantified using digital image analysis. The geometric mean of the percentage area of the cytoplasm occupied by particulates in 50 cover-slip adherent AM was calculated and termed particulate load. RESULTS: In 57 subjects (40 men and 17 women) there was a significant difference between the particulate load in groups divided according to pre-dominant lighting form used at home (ANOVA P = 0.0009) and type of cooking fuel (P = 0.0078). CONCLUSIONS: Particulate load observed in macrophages is associated with the reported type of biomass fuel exposure. Macrophage function in relation to respiratory health should now be investigated in biomass smoke exposed subjects.

Black-pigmented material in airway macrophages from healthy children: association with lung function and modeled PM10.

Epidemiologic studies in children suggest that chronic inhalation of carbonaceous particulate matter < or = 10 pm in aerodynamic diameter (PM10) attenuates the normal growth of lung function. However, the relation between markers of PM10 exposure and the quantity of particles entering the pediatric airway is unclear. Experimental studies have shown that particles entering the lower airway remain visible in the cytoplasm of airway macrophages (AMs) for several months. We hypothesized that particle loading of AMs, detected as black-pigmented material, reflects individual exposure of healthy children to PM10. In this study, we aimed to establish the relation between the median area of black material in AMs (measured as the two-dimensional area of black material ["black area"] per AM per child) and (1) lung function, and (2) level of primary PM10 at the child's home address as estimated by dispersion modeling (referred to as "modeled primary PM10"). We also performed a series of exploratory analyses assessing the association between the median black area in AMs and (1) variables that could modify individual exposure, and (2) airway inflammation. To achieve these aims, AMs were sampled using induced sputum from children in Leicestershire, United Kingdom, and lung function was determined by spirometry. Data from 64 of 116 children who provided adequate induced sputum samples were analyzed. The area of the black material in AMs was determined by an analysis of digitized light-microscopic images of 100 randomly chosen AMs per child. There was a significant inverse association between size of black area in AMs and lung function: each 1.0-microm2 increase in the area of the black material in AMs was associated with a 17.0% (95% confidence interval [CI], 5.6 to 28.4) reduction in forced expiratory volume in one second (FEV1), a 12.9% (95% CI, 0.9 to 24.8) reduction in forced vital capacity (FVC), and a 34.7% (95% CI, 11.3 to 58.1) reduction in forced expiratory flow between 25% and 75% of forced vital capacity (FEF25%-75%). These associations were not affected by bronchodilator treatment. There was also an association between modeled exposure to primary PM10 and area of black material in AMs: each 1.0-microg/m3 increase in primary PM10 was associated with an increase of 0.10 microm2 (95% CI, 0.01 to 0.18) in black area in AMs. There was no significant association between the median black area in AMs and age, height, weight, sex, activity level, and levels of neutrophilic airway inflammation in the induced sputum. We conclude that the median area of black material in AMs in children is a promising marker of individual exposure to carbonaceous PM10 and that our data strengthen the epidemiologic data suggesting that PM10 impairs the growth of lung function in children.

Neutrophils in induced sputum from healthy children: role of interleukin-8 and oxidative stress.

BACKGROUND: It is unclear why the neutrophil differential count in induced sputum (IS) from normal children is highly variable. Since levels of neutrophil chemoattractant cytokines and oxidative stress are determinants of airway neutrophilia in animal models, we sought to determine the association between IS neutrophils from healthy children and (i) interleukin-8 (IL-8) and (ii) the oxidative stress marker 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodG). METHODS: IS was done using hypertonic saline. The proportion (differential %) and the absolute number of IS neutrophils were determined by light microscopy. IS IL-8 and 8-oxodG were determined using ELISA. Spearman's rank correlation (Rs) was used to assess relationship between variables. RESULTS: Adequate IS samples for analysis were obtained from 64/114 healthy children. The median (interquartile range) neutrophil differential count (n=64) was 20.6% (5.67-56), and absolute neutrophil count (n=53) was 0.11x10(6) (0.01-0.77). Both the % neutrophils, and the absolute neutrophil count were associated with IL-8 (Rs=0.67, p<0.0001 and 0.60, p<0.0001, respectively), but there was no association between IS neutrophil variables and 8-oxodG (n=40). The repeatability (intraclass correlation coefficient-Ri) of the neutrophil differential count was 0.58 (n=15). CONCLUSIONS: The variation in the proportion and number of neutrophils in the lower airway of healthy children is associated with IL-8, but not with oxidative stress. The IS neutrophil differential count in healthy children is relatively stable over several months.

Carbon in airway macrophages and lung function in children.

BACKGROUND: Epidemiologic studies indirectly suggest that the inhalation of carbonaceous particulate matter impairs lung function in children. Using the carbon content of airway macrophages as a marker of individual exposure to particulate matter derived from fossil fuel, we sought direct evidence of this association. METHODS: Airway macrophages were obtained from healthy children through sputum induction, and the area of airway macrophages occupied by carbon was measured. Lung function was measured with the use of spirometry. We modeled the exposure to primary particulate matter (PM) that is less than 10 mum in aerodynamic diameter (PM10) at or near each child's home address. Linear regression was used to evaluate associations between carbon content of alveolar macrophages and variables that may affect individual exposure. To determine whether lung function that is reduced for other reasons is associated with an increase in the carbon content of airway macrophages, we also studied children with severe asthma. RESULTS: We were able to assess the carbon content of airway macrophages in 64 of 114 healthy children (56 percent). Each increase in primary PM10 of 1.0 microg per cubic meter was associated with an increase of 0.10 microm2 (95 percent confidence interval, 0.01 to 0.18) in the carbon content of airway macrophages, and each increase of 1.0 microm2 in carbon content was associated with a reduction of 17 percent (95 percent confidence interval, 5.6 to 28.4 percent) in forced expiratory volume in one second, of 12.9 percent (95 percent confidence interval, 0.9 to 24.8 percent) in forced vital capacity, and of 34.7 percent (95 percent confidence interval, 11.3 to 58.1 percent) in the forced expiratory flow between 25 and 75 percent of the forced vital capacity. The carbon content of airway macrophages was lower in children with asthma than in healthy children. CONCLUSIONS: There is a dose-dependent inverse association between the carbon content of airway macrophages and lung function in children. We found no evidence that reduced lung function itself causes an increase in carbon content.

Carbon loading of alveolar macrophages in adults and children exposed to biomass smoke particles.

Exposure to carbonaceous particles from biomass burning is associated with increased respiratory morbidity in both women and children in the developing world. However, the amount of carbon reaching lower airway cells has not been determined in these populations. Alveolar macrophages (AM) remove inhaled particulate matter (PM), and are implicated in the pathogenesis of PM-induced lung disease. In this study, we aimed to compare AM carbon loading in women and children exposed to biomass PM in Gondar, Ethiopia, with individuals exposed to fossil-fuel PM in the developed world (Leicester, UK). To achieve these aims, we sampled AM from Ethiopian mothers and children, and from UK adults and children using induced sputum (IS). AM were imaged under light microscopy, and the total two-dimensional surface area of carbon within each AM determined by image analysis. AM containing carbon were detected in all subjects. The total surface area of carbon per AM was higher in Ethiopian women (n=10) compared with UK adults (n=10, median 9.19 vs. 0.71 microm2/AM, p=0.0002). Similarly, the total surface area of carbon per AM was higher in Ethiopian children (n=10) compared with UK children (n=10, 3.32 vs. 0.44 microm2/AM, p=0.0002). However, loading in Ethiopian children was lower than paired maternal levels (3.32 vs. 9.19 microm2/AM, p=0.011). We conclude that analysis of AM obtained by induced sputum is a practical way of quantifying natural exposure of the lower airway to carbonaceous particles from the burning of biomass fuels.