Adherence to the asthma pathway, including pre-triage bronchodilator history, reduces hospitalizations.

Objective: To determine if adherence to an asthma treatment pathway is associated with a decrease in hospitalizations.Methods: A prospective cohort design was conducted of Thai children aged 2-15 years who visited the emergency department with severe asthma exacerbations, defined as a Buddhasothorn Asthma Severity Score ≥ 8. Patients who received systemic corticosteroids and nebulized short-acting beta-2 agonists combined with ipratropium bromides were classified as the adherence group. The timing of steroid and bronchodilator administration, length of hospital stay, and hospitalization rate were examined in relation to adherence to the asthma pathway. Multivariable logistic regression models and adjusted odds ratios were used to assess associations.Results: A total of 118 episodes of asthma exacerbations (EAEs) from 59 participants were included. Patients who adhered to the pathway had a significantly higher rate of systemic corticosteroid administration within 1 h of arrival at triage (88.6% vs. 41.9%, adjusted Odds Ratio: aOR 10.21; 95%CI 3.52-29.62). A higher proportion of the patients who adhered to the pathway also received inhaled ipratropium bromide ≥ 2 doses within 1 h of arrival at triage (72.7% vs. 12.2%, aOR 23.51; 95%CI 7.73-71.54) and it was administered significantly faster by 31 min (5 min vs. 36 min, p < 0.001) compared to non-adherence group. The hospitalization rate was significantly lower by almost half of EAEs for adherence group (36.4% vs. 63.5%, aOR 0.41; 95%CI 0.18-0.93).Conclusions: Accurate assessment of severity and adherence to the clinical pathway can reduce hospitalization in pediatric patients with severe asthma exacerbations.

The Buddhasothorn Asthma Severity Score (BASS): A practical screening tool for predicting severe asthma exacerbations for pediatric patients.

BACKGROUND AND AIM: A precise scaling system of acute asthma leads to an accurate assessment of disease severity. This study aimed to compare the accuracy of the Buddhasothorn Asthma Severity Score (BASS) with the Wood-Downes-Ferrés Scale (WDFS) to recognize the severity level of acute asthma. MATERIALS AND METHODS: A cross-sectional study was conducted comprising Thai children aged 2-15 years with acute asthma. The BASS and WFDS were rated once in the emergency department. The degree of severity was determined by frequency and type of nebulized bronchodilator administrations at the time of initial treatment. The optimum cutoff points for the area under the curve (AUC) were established to predict severe asthma exacerbations. RESULTS: All 73 episodes of asthma exacerbations (EAEs) in 35 participants were analyzed. Fifty-nine (80.8%) EAEs were classified as severe. Both scales had good significance to recognize the selection of nebulized bronchodilator treatments by AUC of 0.815 (95% Confidence Interval [CI]: 0.680-0.950) in case of BASS, and AUC of 0.822 (95% CI: 0.70-0.944) in case of WDFS. Cutoff points of BASS ≥ 8 had sensitivity 72.9%, specificity 64.3%, positive predictive value (PPV) 89.6%, negative predictive value (NPV) 36.0% at an AUC of 0.718 (95% CI: 0.563-0.873) for severe exacerbations. These results were consistent for cutoff points of WDFS ≥ 5 with sensitivity 78.0%, specificity 50.0%, PPV 86.8%, NPV 35.0% at an AUC of 0.768 (95% CI: 0.650-0.886) for predicting severe exacerbations. There was no significant difference between the AUCs of both scales. CONCLUSIONS: Both the BASS and WDFS were good and accurate scales and effective screening tools for predicting severe asthma exacerbations in pediatric patients by optimal cutoff points.

The implementation of pediatric asthma guidelines including self-assessment of the level of confidence and accessibility of medical supplies necessary for asthma management from the perspectives of multidisciplinary care teams.

BACKGROUND: Asthma control in Thai children is not yet satisfactory. Direct observation of the clinical practice for health care professionals (HCPs) in asthma clinic is essential. OBJECTIVE: To ascertain the implementation of asthma guidelines for Thai children, to assess the confidence level in general asthma management, and to determine the availability of medical supplies. METHODS: A cross-sectional study was conducted in which HCPs were surveyed by questionnaire. The selection of pediatric asthma guidelines and self-assessment of their confidence level of their own asthma practice were assessed by using a score range between 1 (the lowest) and 10 (the highest). Reasons for low confidence were identified. The necessity and availability of medical supplies for asthma and its comorbidities were investigated in government hospitals in Chachoengsao province. RESULTS: A total of 245 participants from 11 hospitals were enrolled. There were registered nurses (38.0%), medical and nursing students (31.4%), physicians (28.2%), and pharmacists (2.4%). The Global Initiative for Asthma has been the most frequently used guideline followed by the Thai Asthma Guideline for Children 2015-2016 (56.3% vs. 52.7%; p = 0.45). The pathway for assessment and stepwise approach for adjusting treatment was the most regularly applied (61.4%). The mean overall level of confidence was 5.72 & 1.70-a moderate level. Only 2 of 11 (18.2%) surveyed hospitals had nebulized corticosteroids, and less than half of them (45.5%) had an allergic rhinitis checklist. CONCLUSIONS: To perfectly implement the national asthma guidelines, HCPs should be able to increase the level of confidence and procure necessary medical supplies.

Natural resolution of non-anaphylactic shrimp allergy in patients diagnosed 10 years earlier by oral food challenge.

BACKGROUND: Shrimp allergy is considered a lifelong condition. The natural resolution of shrimp allergy is not well studied. OBJECTIVE: To investigate the natural resolution of shrimp allergy among a cohort of patients diagnosed with shrimp allergy 10 years earlier by oral shrimp challenge. METHODS: A prospective study recruited patients diagnosed with shrimp allergy to Penaeus monodon (Pm), Macrobrachium rosenbergii (Mr), or both from a study conducted during 2005-2006. The current oral shrimp challenges were conducted during 2015-2016. The negative oral shrimp challenge was designated 'resolved shrimp allergy' (RSA), with a positive challenge designated 'persistent shrimp allergy' (PSA). Skin prick and prick-to-prick testing to shrimp were used to determine sensitization. RESULTS: Sixty patients who had positive shrimp challenge from the previous cohort were contacted. Patients who had previous anaphylactic reaction (8 subjects) or allergic reaction after shrimp ingestion within 6 months (6 subjects), were not included. Nine patients refused to participate and 20 patients could not be contacted. Seventeen patients were included. Three were previously diagnosed with allergy to Pm, 3 to Mr, and 11 to both species. RSA was observed in 1 patient with isolated Pm allergy, and in 3 patients with isolated Mr allergy. Three of 9 patients with dual allergy had RSA to both species. RSA patients had significantly smaller size of shrimp skin test than PSA patients at both diagnosis and follow-up. CONCLUSIONS: At ten years after diagnosis, 46% of patients had RSA. These patients had significantly smaller size of shrimp skin test than PSA patients.

Habitual snoring coexisting with respiratory allergies in children: Prevalence and impact on quality of life extending beyond primary snoring.

Background: Children who have respiratory allergies are more likely to experience sleep disturbances. Persistent sleep-disordered breathing directly contributes to poor symptom control for asthma and allergic rhinitis, including deterioration in quality of life. This study aimed to investigate the prevalence, risk factors of habitual snoring, and the correlation between 18-item obstructive sleep apnea (OSA-18) scores and the level of asthma and allergic rhinitis (AR) symptoms control for habitual snorers with respiratory allergies. Material and methods: A cross-sectional design was conducted on Thai children aged 2 to 15 who were diagnosed with asthma and AR in a respiratory allergy clinic at the Medical Education Center. The Pediatric Sleep Questionnaire was used to determine the prevalence of habitual snoring. Patients with habitual snoring completed the OSA-18 quality of life questionnaire, which was divided into 5 subscales: sleep disturbance, physical symptoms, emotional distress, daytime function, and caregiver concerns. Symptom control for asthma and AR was evaluated according to the Global Initiative for Asthma (GINA) guidelines and the Visual Analog Scales (VAS), respectively. Multivariable logistic regression models and adjusted odds ratios were used to assess associations. Results: A total of 565 participants were enrolled, and 363 (64.2%) were male. Habitual snoring had the highest prevalence of sleep-disordered breathing in 29.6% of patients with respiratory allergies. Patients with poorly controlled symptoms had a significantly higher risk of habitual snoring than well controlled symptoms for AR (52.0% vs 19.1%, adjusted Odds Ratio: aOR 4.39, 95%CI 2.25-8.58, p < 0.001) and for asthma concomitant with AR (54.9% vs. 18.8%, aOR 5.18, 95%CI 2.52-10.68, p < 0.001). Habitual snorers with poorly controlled asthma negatively affected their quality of life more than those with well controlled asthma (37.7% vs 13.3%, p = 0.005), as did patients with underlying AR (46.2% vs 22.9%, p = 0.002). In comparison to habitual snorers with well controlled symptoms, those with poorly controlled symptoms for respiratory allergies had higher mean the OSA-18 scores across all subscales. Conclusion: Nearly one-third of children with respiratory allergies develop habitual snoring. Poorly controlled symptoms of asthma and allergic rhinitis raise the possibility of developing habitual snoring. Their quality of life and caregivers were shown to be affected just as negatively as those with obstructive sleep apnea (OSA) syndrome.

Defining Biomarkers to Predict Natural Resolution in Shrimp Allergy.

PURPOSE: Tolerance to shrimp has been reported in some patients with a history of shrimp allergy. The predictors of the natural resolution of shrimp allergy have not been widely explored. This study aimed to investigate the role of specific IgE (sIgE) and specific IgG4 (sIgG4) to shrimp extracts and the cross-reactive shrimp allergens tropomyosin (TM), arginine kinase (AK) and myosin light-chain (MLC), as markers of persistent or resolved shrimp allergy (PSA or RSA). METHODS: Seventeen patients with a 10-year history of allergy to Penaeus monodon (Pm) and/or Macrobachium rosenbergii (Mr) were recruited. Oral shrimp challenges identified 10 patients with PSA and 7 patients with RSA. Sera from these patients were evaluated for sIgE and sIgG4 to Mr and Pm extracts as well as to TM, AK and MLC. RESULTS: The levels of sIgE to Mr and Pm extracts were lower in the RSA than in the PSA groups (P = 0.05 and P = 0.008, respectively), but sIgG4 or sIgG4:sIgE ratio did not show statistical significance. The sIgE to AK and MLC, but not TM, were lower in the RSA group than in the PSA group (P = 0.009 and P = 0.0008, respectively). There was no difference in sIgG4 to TM, AK and MLC between both groups. The ratio of sIgG4:sIgE to MLC, but not TM or AK, was higher in the RSA than in the PSA group (P = 0.02). A higher diversity of sIgE to shrimp components was found in the PSA group than in the RSA group (P = 0.006). CONCLUSIONS: Specific bioassays can be used to identify patients with RSA. Oral shrimp challenges in these patients may provide a higher rate of passing the challenges and finally reintroducing shrimp in their diet.