Optimizing care for children with difficult-to-treat and severe asthma through specialist paediatric asthma centres: expert practical experience and advice.

Severe asthma in children carries an unacceptable treatment burden, yet its rarity means clinical experience in treating it is limited, even among specialists. Practical guidance is needed to support clinical decision-making to optimize treatment for children with this condition.This modified Delphi convened 16 paediatric pulmonologists and allergologists from northern Europe, all experienced in treating children with severe asthma. Informed by interviews with stakeholders involved in the care of children with severe asthma (including paediatricians, nurses and carers), and an analysis of European guidelines, the experts built a consensus focused on the gaps in existing guidance. Explored were considerations for optimizing care for patients needing biologic treatment, and for selecting home or hospital delivery of biologics. This consensus is aimed at clinicians in specialist centres, as well as general paediatricians, paediatric allergologists and paediatric pulmonologists who refer children with the most severe asthma to specialist care. Consensus is based on expert opinion and is intended for use alongside published guidelines.Our discussions revealed three key facets to optimizing care. Firstly, early asthma detection in children presenting with wheezing and/or dyspnoea is vital, with a low threshold for referral from primary to specialist care. Secondly, children who may need biologics should be referred to and managed by specialist paediatric asthma centres; we define principles for the specialist team members, tests, and expertise necessary at such centres, as well as guidance on when homecare biologics delivery is and is not appropriate. Thirdly, shared decision-making is essential at all stages of the patient's journey: clear, concise treatment plans are vital for patient/carer self-management, and structured processes for transition from paediatric to adult services are valuable. The experts identified the potential for specialist paediatric asthma nurses to play a significant role in facilitating multidisciplinary working.Through this project is agreed a framework of practical advice to optimize the care of children with severe asthma. We encourage clinicians and policymakers to implement this practical advice to enhance patient care.

Systemic treatment of children and adolescents with atopic dermatitis aged ≥2 years: a Delphi consensus project mapping expert opinion in Northern Europe.

BACKGROUND: Paediatric atopic dermatitis (AD) can be burdensome, affecting mental health and impairing quality of life for children and caregivers. Comprehensive guidelines exist for managing paediatric AD, but practical guidance on using systemic therapy is limited, particularly for new therapies including biologics and Janus kinase (JAK) inhibitors, recently approved for various ages in this indication. OBJECTIVES: This expert consensus aimed to provide practical recommendations within this advancing field to enhance clinical decision-making on the use of these and other systemics for children and adolescents aged ≥2 years with moderate-to-severe AD. METHODS: Nineteen physicians from Northern Europe were selected for their expertise in managing childhood AD. Using a two-round Delphi process, they reached full or partial consensus on 37 statements. RESULTS: Systemic therapy is recommended for children aged ≥2 years with a clear clinical diagnosis of severe AD and persistent disease uncontrolled after optimizing non-systemic therapy. Systemic therapy should achieve long-term disease control and reduce short-term interventions. Recommended are cyclosporine A for short-term use (all ages) and dupilumab or methotrexate for long-term use (ages ≥6 years). Consensus was not reached on the best long-term systemics for children aged 2-6 years, although new systemic therapies will likely become favourable: New biologics and JAK inhibitors will soon be approved for this age group, and more trial and real-world data will become available. CONCLUSIONS: This article makes practical recommendations on the use of systemic AD treatments for children and adolescents, to supplement international and regional guidelines. It considers the systemic medication that was available for children and adolescents with moderate-to-severe AD at the time this consensus project was done: azathioprine, cyclosporine A, dupilumab, methotrexate, mycophenolate mofetil and oral glucocorticosteroids. We focus on the geographically similar Northern European countries, whose healthcare systems, local preferences for AD management and reimbursement structures nonetheless differ significantly.

Field quadrant asymmetry in perimetric thresholds: results of normal and red-green-deficient persons.

Perimetric thresholds of normal and red-green-deficient persons were measured using three colored test stimuli and a low-intensity white background. Meridians of 45 degrees, 135 degrees, 225 degrees and 315 degrees were tested within 30 degrees peripherally. A statistically significant sensitivity difference between the quadrants was found at eccentricities of 5-30 degrees from the center with the highest sensitivity in the lower temporal field and the lowest one in the upper nasal field, this difference being slightly larger when tested with red (615 nm) or violet (443 nm) light compared with blue-green (497 nm) test light. No difference in the field quadrant sensitivity was observed between the results of the series of normal and red-green-deficient persons.

Perimetric testing of tritan deficiency.

Three members of a family with dominantly inherited juvenile optic atrophy tested with a computerized perimeter employing violet and blue-green test lights and low-intensity white background, all showed larger reduction in the relative sensitivity to violet light in the more central parts of the visual field compared with the periphery within 30 degrees from the center. Two subjects had typical optic atrophy, centrocecal scotoma and lower than normal visual acuity. In 1 subject with good visual acuity of both eyes, no optic atrophy was observed but there was impairment in the luminosity function (tested with white test object on white background) of the peripheral visual field.

Rod thresholds in dominantly inherited juvenile optic atrophy.

Three members of a family with dominantly inherited juvenile optic atrophy with tritan type of colour vision deficiency all showed dysfunction of the rod mechanism tested with green light after 30 min of dark adaptation. Two subjects had typical optic atrophy, centrocaecal scotoma and lower than normal visual acuity. In 1 subject with good visual acuity of both eyes, no optic atrophy was observed, but there were, in this case, reduced peripheral parts of the standard visual fields.

Visual thresholds measured with red test object on backgrounds of high and low luminance.

Visual thresholds measured at the central and midperipheral visual field have been tested in the eyes of a series of 10 healthy normal persons using a monochromatic red test light object (Goldmann area III, 25' of arc in the visual field) of 632 nm wavelength presented on white backgrounds of 150 cd/m2 (5000 K) and 1 cd/m2 (2800 K) luminance, as well as with no background illumination following a 45 min period of dark-adaptation. Another series of 10 normal subjects were tested with an equally large white (2800 K) test object shown on a white background of 1 cd/m2 (2800 K) luminance. Results obtained in congenital and acquired achromatopsia as well as in three relatively mild cases of rod-cone dystrophy have been related to the normal thresholds.

Photopic tangential perimetry.

A large absolute paracentral ring scotoma was found in both eyes of a 60-year-old woman with progressive cone dysfunction but with normal rod function using for the perimetry a white tangential screen of 200 cd/m2 luminance and a 632 nm laser test light. No visual field defect could be found in this patient using the Goldmann perimeter employing white test objects on the standard 10 cd/m2 white background. Further developments of a photopic tangential perimetry system are suggested.

Rod saturation perimetry. Testing of the cone function with achromatic objects.

Restriction of the visual fields in bright illumination and return of the peripheral field in lower illumination were the main complaints of a 59-year-old woman with slowly progressive cone dysfunction and normal rod function. She had normal central visual acuity, normal central color vision, and normal visual fields when tested with the standard Goldmann perimeter. A large ring scotoma was demonstrated in both of her eyes, using tangential perimetry employing a white background of 85% reflection and test objects darker than the background. Using a background of 250 candelas/sq m, which caused a complete saturation of the rod function, the scotoma was absolute. Black test objects of 5% reflection were not seen.

Visual thresholds in the deutan type of red-green deficient colour vision.

Defective temporal integration for a foveally fixated 100' of arc red (660 nm) Btest flash presented on a 30 cd/m2 yellow ( Schott , OG 530) background was measured in subjects with deuteranopia , as well as in subjects with anomalous trichromacy of the deutan type. The mean integration time was 77 +/- 17 ms in 12 normal subjects but only 35 +/- 6, 46 +/- 11 Band 41 +/- 15 ms in respectively 6 subjects with deuteranopia , 7 with extreme deuteranomaly Band 9 with deuteranomaly . An increase in the test duration from 10 to 200 ms increased the mean relative sensitivity by 0.85 +/- 13 log units in the normal subjects compared with 0.45 +/- 0.05, 0.57 +/- 12 and 0.56 +/- 19 in subjects with deuteranopia , extreme deuteranomaly and deuteranomaly .