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Medical Journal Review

July 2020

WAO Reviews – Editors' Choice

The Editors’ Choice comes to you from Juan Carlos Ivancevich, MD, and John J. Oppenheimer, MD, FACAAI, FAAAAI. They select articles for their importance to clinicians who care for patients with asthma and allergic/immunologic diseases, and whenever possible, for their accessibility to everyone.

Digital transformation of health and care to sustain planetary health: The MASK proof-of-concept for airway diseases – POLLAR symposium  under the auspices of Finland’s Presidency of the EU, 2019 and MACVIA – France, Global Alliance against Chronic Respiratory Diseases (GARD, WHO) demonstration project, Reference Site Collaborative Network of the European Innovation Partnership on Active and Healthy Ageing
Bousquet J, Anto JM, Haahtela T, Pekka J, Erhola M et al.
Clinical and Translational Allergy 2020; 10:24 (19 June)
https://doi.org/10.1186/s13601-020-00321-2

In December 2019, a conference entitled “Europe That Protects: Safeguarding Our Planet, Safeguarding Our Health”, was held in Helsinki which was co-organized by the Finnish Institute for Health and Welfare, and the Finnish Environment Institute and the European Commission. In this meeting a “side-symposium” organized as the final POLLAR (Impact of air POLLution on Asthma and Rhinitis) meeting explored the digital transformation of health and care to sustain planetary health in airway diseases. The Finnish Allergy Programme collaborates with MASK (Mobile Airways Sentinel NetworK) and can be considered as a proof-of-concept to impact Planetary Health. The Good Practice of DG Santé (The Directorate-General for Health and Food Safety) on digitally enabled, patient-centred care pathways is in line with the objectives of the Finnish Allergy Programme. The ARIAC‑ARE-Digital network has been deployed in 25 countries. It represents an example of the digital cross-border exchange of real-world data and experience with the aim to improve patient care. The integration of information technology tools for climate, weather, air pollution, and aerobiology in mobile health applications will enable the development of an alert system. Citizens thus will be informed about personal environmental threats, which may also be linked to indicators of planetary health and sustainability. The digital transformation of the public health policy was also proposed, following the experience of the Agency for Health Quality and Assessment of Catalonia (AQuAS).

Assessment of acute acral lesions in a case series of children and adolescents during the COVID-19 pandemic
Roca-Ginés J, Torres-Navarro I, Sánchez-Arráez J, Abril-Perez C, Sabalza-Baztán O et al.
JAMA Dermatology 2020; Published online ahead of print (25 June)
https://doi.org/10.1001/jamadermatol.2020.2340

Children and adolescents infected with Covid-19 have been noted to have associated skin diseases referred to as acute acro-ischemia. In this study by Roca-Ginés et al, the authors evaluated the pathogenesis of these newly described lesions by performing a prospective case series, conducted at a tertiary referral hospital in Valencia, Spain, between April 9 and April 15, 2020. Among 32 referred patients, 20 children and adolescents with new-onset inflammatory lesions did not have a diagnosis and underwent evaluation with reverse transcriptase–polymerase chain reaction for SARS-CoV-2 and a range of blood tests for possible origins of the lesions. Evaluation included skin biopsies in 6 patients. Ultimately, they could not find a relationship between acute acral skin changes and COVID-19.

The risk of osteoporosis in patients with asthma
Kumarathas I, Harsløf T, Uggerhøj Andersen C, Langdahl B, Hilberg O et al.
European Clinical Respiratory Journal 2020;7(1):1763612 (19 May)
https://doi.org/10.1080/20018525.2020.1763612

While it is well known that use of continuous systemic corticosteroids (SG) affects bone metabolism, bone mineral density (BMD), and ultimately increases the risk of osteoporosis, the impact of long-term high-dose inhaled corticosteroids (ICS) on BMD and risk of osteoporotic fractures is less well understood.  The reasons for this uncertainty include the following: few long-term studies investigating the effect of ICS in patients with asthma; disparities in study designs and duration of ICS exposure; small study populations; and differences between the used ICS. In this article, Kumarathas and colleagues explore this literature to understand better the potential risk of long-term ICS therapy, finding that ICS treatment may have a dose-dependent effect on bone metabolism and subsequently risk of fracture. There are, however, inconsistencies in the results from these studies, which might be due to other confounders, such as smoking, sedentary lifestyle, a higher systemic inflammation, and the need for frequent intermittent or continuous SG or high-dose ICS. In the end, the authors stress that ICS are highly effective drugs in patients with asthma, and through their reduction in inflammation and disease activity, they may reduce the need for frequent oral corticosteroids; however, patients should be advised to use the lowest effective dose that adequately controls their asthma. Certainly, further research regarding the long-term safety of high-dose ICS is needed.

Neuroinflammatory gene expression pattern is similar between allergic rhinitis and atopic dermatitis but distinct from atopic asthma
Sobkowiak p, Langwiński W, Nowakowska J, Wojsyk-Banaszak I, Szczepankiewicz D et al.
Biomed Research International 2020:7196981 (10 June)
https://doi.org/10.1155/2020/7196981

Neurogenic inflammation underlies the pathogenesis of allergic diseases with interactions between neurons with immune cells and structural cells (airway epithelium, nasal mucosa, skin keratinocytes). To better understand this issue, the authors explored how the expression of neuroinflammatory genes may be in altered allergic diseases, including atopic dermatitis, allergic rhinitis, and atopic asthma by studying  86 children diagnosed with atopic asthma (n = 25), allergic rhinitis (n = 20), and atopic dermatitis (n = 20) and healthy control subjects (n = 21).  The blood leukocyte expression of 31 genes involved in neuroinflammatory response (neurotrophins, their receptors, neuropeptides, and histamine signaling pathway) was analyzed using TaqMan low-density arrays. They found that blood expression of 31 genes related to neuroimmune interactions showed significant increase in both allergic rhinitis and atopic dermatitis, in comparison to the control group, with 12 genes significantly increased in allergic rhinitis and 9 genes in in atopic dermatitis. Moreover, 9 genes with changed expression in atopic dermatitis overlapped with those in allergic rhinitis. Atopic asthma showed 5 genes with altered expression. The authors suggest that the common pattern of neuroinflammatory gene expression between allergic rhinitis and atopic dermatitis may reflect similar changes in sensory nerve function during chronic allergic inflammation.

Prevalence and characterization of asthma in hospitalized and non-hospitalized patients with COVID-19
Chhiba KD, Patel GB, Vu THT, Chen MM, Guo A et al.
Journal of Allergy and Clinical Immunology 2020; Published online ahead of print (15 June)
https://doi.org/10.1016/j.jaci.2020.06.01

The Centers for Disease Control and Prevention (CDC) advises that patients with moderate-to-severe asthma belong to a high-risk group that is susceptible to severe COVID-19; yet, this association has not been well established.  To understand this potential association better, Chhiba and colleagues examined the prevalence of asthma among COVID-19 patients in a major U.S. health system via examining medical records of patients with COVID-19 using a computer algorithm. All patients had PCR-confirmed COVID-19. Of 1,526 patients identified with COVID-19, 220 (14%) were classified as having asthma. They found that asthma was not associated with an increased risk of hospitalization (RR of 0.96 [95%CI: 0.77-1.19]), after adjusting for age, sex, gender, and comorbidities. Furthermore, the ongoing use of ICS did not increase the risk of hospitalization in a similar adjusted model (RR of 1.39 [95%CI: 0.90-2.15]).  Overall, this should be reassuring, as both the diagnosis of asthma as well as use of ICS was not associated with

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