Showing papers by "Atul Gupta published in 2021"

Paediatric and adolescent asthma: A narrative review of telemedicine and emerging technologies for the post-COVID-19 era.

Abstract: Children and young people with asthma need regular monitoring to maintain good asthma control, prevent asthma attacks and manage comorbidities. The COVID-19 pandemic has resulted in healthcare professionals making fundamental changes to the way healthcare is delivered and for patients and families adapting to these changes. Comprehensive remotely-delivered, technology-based healthcare, closer to the patients home (reducing hospital footfall and possibly reducing carbon footprint) is likely to be one of the important collateral effects of the pandemic. Telemedicine is anticipated to impact everyone involved in healthcare - providers and patients alike. It is going to bring changes to organisation, work areas and work culture in healthcare. Healthcare providers, policymakers and those accessing healthcare services will experience the impact of technology-based healthcare delivery. Telemedicine can play an exciting role in the management of childhood asthma by delivering high quality care closer to the child's home. However, unlike adults, children still need to be accompanied by their carers for virtual care. Policymakers will need to take into account potential additional costs as well as the legal, ethical and cultural implications of large scale use of telemedicine. In this narrative review we review evidence regarding the role of telemedicine and related emerging technologies in paediatric and adolescent asthma. Although there are gaps in the current knowledge, there is evidence demonstrating the important role of telemedicine in management of childhood and adolescent asthma. However, there is an urgent need for healthcare researchers and policymakers to focus on improving the technologies and address the disparities in accessing novel technology based management strategies to improve asthma care.

Vitamin-D supplementation as an adjunct to standard treatment of asthma in children: A randomized controlled trial (ViDASTA Trial).

Abstract: OBJECTIVE To determine the role of vitamin D supplementation as an adjunct to standard treatment in childhood asthma STUDY DESIGN In this placebo-controlled, blinded, randomized controlled trial, we enrolled 60 children aged 6 to 11 years with moderate persistent asthma and randomly assigned them into intervention (2000 IU per day of vitamin D) and placebo groups (n = 30 each) The primary outcome was asthma control as assessed by the childhood asthma control test (C-ACT) scores at 12 weeks post-randomization The secondary outcomes were improvement in the forced expiration in 1 s (FEV1 ), fractional exhaled nitric oxide (FeNO), asthma exacerbations, use of systemic steroids, number of emergency visits, post-intervention vitamin D levels, and adverse outcomes We analyzed by intention to treat RESULTS There was no significant difference between the C-ACT score in the two groups (median [first-third quartile] scores were 25 [24-26] in both groups, p = 07) Also, there was no significant difference between the two groups in terms of the FEV1 , FeNO, number of exacerbations, emergency visits, hospital admissions, and adverse outcomes However, the post-intervention vitamin D levels (ng/ml) were significantly higher in the intervention group (355 vs 188; p < 0001) As compared to the baseline, both the groups showed better asthma control at 12 weeks post-intervention, irrespective of the type of intervention CONCLUSION Vitamin-D supplementation as an adjunct to standard treatment does not improve asthma control in children

The burden of sleep disordered breathing in children with sickle cell disease.

Abstract: Children with sickle cell disease (SCD) have an increased risk of sleep disordered breathing (SDB) compared with the general pediatric population. There has been a growing research interest on this field in recent years, yet many questions regarding risk factors and clinical implications of SDB remain unclear. The aim of this review is to provide a concise narrative and systematic synthesis of the available evidence on the epidemiology, clinical presentation, complications, and management, of SDB in children with SCD. An electronic search was conducted on studies published from the 1st of January 2000 to the 31st of December 2020 in PubMed/Medline, Scopus, and Cochrane databases. All studies focusing on SDB in children with SCD aged from 0 to 20 years were included. Studies were eligible for inclusion if available in the English language. A quantitative synthesis of the included studies was performed. Only studies focusing on specific treatment outcomes were included in a meta-analytic process. A total of 190 papers were initially identified. After screening the title and abstract, 112 articles were evaluated for eligibility. At the end of the selection process, 62 studies were included in the analysis. Sleep disordered breathing is associated with worse neurological, neurocognitive, and cardiological outcomes, whereas the association with frequency or severity of vaso-occlusive pain events and acute chest syndrome was not clarified. Therapeutic interventions like adenotonsillectomy or oxygen supplementation may result in a significant increase in mean nocturnal oxygen saturation but effective clinical implications remain still unclear.

Blood eosinophils in managing preschool wheeze: Lessons learnt from a proof-of-concept trial.

Abstract: BACKGROUND Management of preschool wheeze is based predominantly on symptom patterns. OBJECTIVE To determine whether personalizing therapy using blood eosinophils or airway bacterial infection results in fewer attacks compared with standard care. METHODS A proof-of-concept, randomized trial to investigate whether the prescription of inhaled corticosteroids (ICS) guided by blood eosinophils, or targeted antibiotics for airway bacterial infection, results in fewer unscheduled healthcare visits (UHCVs) compared with standard care. Children aged 1-5 years with ≥2 wheeze attacks in the previous year were categorized as episodic viral wheeze (EVW) or multiple trigger wheeze (MTW). The intervention group was prescribed ICS if blood eosinophils ≥3%, or targeted antibiotics if there is positive culture on induced sputum/cough swab. The control group received standard care. The primary outcome was UHCV at 4 months. RESULTS 60 children, with a median age of 36.5 (range 14-61) months, were randomized. Median blood eosinophils were 5.2 (range 0-21)%, 27 of 60 (45%) children were atopic, and 8 of 60 (13%) had airway bacterial infection. There was no relationship between EVW, MTW and either blood eosinophils, atopic status or infection. 67% in each group were prescribed ICS. 15 of 30 control subjects and 16 of 30 patients in the intervention group had UHCV over 4 months (p = .8). The time to first UHCV was similar. 50% returned adherence monitors; in those, median ICS adherence was 67%. There were no differences in any parameter between those who did and did not have an UHCV. CONCLUSION Clinical phenotype was unrelated to allergen sensitization or blood eosinophils. ICS treatment determined by blood eosinophils did not impact UHCV, but ICS adherence was poor.

Study of montelukast in children with sickle cell disease (SMILES): a study protocol for a randomised controlled trial.

Abstract: Young children with sickle cell anaemia (SCA) often have slowed processing speed associated with reduced brain white matter integrity, low oxygen saturation, and sleep-disordered breathing (SDB), related in part to enlarged adenoids and tonsils. Common treatments for SDB include adenotonsillectomy and nocturnal continuous positive airway pressure (CPAP), but adenotonsillectomy is an invasive surgical procedure, and CPAP is rarely well-tolerated. Further, there is no current consensus on the ability of these treatments to improve cognitive function. Several double-blind, randomised controlled trials (RCTs) have demonstrated the efficacy of montelukast, a safe, well-tolerated anti-inflammatory agent, as a treatment for airway obstruction and reducing adenoid size for children who do not have SCA. However, we do not yet know whether montelukast reduces adenoid size and improves cognition function in young children with SCA. The Study of Montelukast In Children with Sickle Cell Disease (SMILES) is a 12-week multicentre, double-blind, RCT. SMILES aims to recruit 200 paediatric patients with SCA and SDB aged 3–7.99 years to assess the extent to which montelukast can improve cognitive function (i.e. processing speed) and sleep and reduce adenoidal size and white matter damage compared to placebo. Patients will be randomised to either montelukast or placebo for 12 weeks. The primary objective of the SMILES trial is to assess the effect of montelukast on processing speed in young children with SCA. At baseline and post-treatment, we will administer a cognitive evaluation; caregivers will complete questionnaires (e.g. sleep, pain) and measures of demographics. Laboratory values will be obtained from medical records collected as part of standard care. If a family agrees, patients will undergo brain MRIs for adenoid size and other structural and haemodynamic quantitative measures at baseline and post-treatment, and we will obtain overnight oximetry. Findings from this study will increase our understanding of whether montelukast is an effective treatment for young children with SCA. Using cognitive testing and MRI, the SMILES trial hopes to gain critical knowledge to help develop targeted interventions to improve the outcomes of young children with SCA. ClinicalTrials.gov NCT04351698 . Registered on April 17, 2020. European Clinical Trials Database (EudraCT No. 2017-004539-36). Registered on May 19, 2020

Fifteen-minute consultation: A structured approach to a child with primary spontaneous pneumothorax

Abstract: Primary spontaneous pneumothorax (PSP) is an uncommon presentation in children but may occur at any age and occurs in patients with no pre-existing lung disease. Management aims are to re-expand the collapsed lung, relieve pressure in the intrapleural space and avoid a tension pneumothorax. Correct management of PSP will avoid unnecessary intervention, reduce length of hospital stay and also reduce the risk of recurrence. There are no established guidelines for treating PSP in children and there is significant variation in management among centres and clinicians. This article provides a clear, evidence-based and structured approach to assessment and management of PSP in children and young people.

The Induction of Alpha-1 Antitrypsin by Vitamin D in Human T Cells Is TGF-β Dependent: A Proposed Anti-inflammatory Role in Airway Disease

Abstract: Background: Vitamin D upregulates anti-inflammatory and antimicrobial pathways that promote respiratory health. Vitamin D synthesis is initiated following skin exposure to sunlight, however nutritional supplementation can be required to address deficiency, for example during the winter months or due to cultural constraints. We recently reported that 1α,25-dihydroxyvitamin D3 (1,25(OH)2D3) treatment induced alpha-1 antitrypsin (AAT) expression in CD4+, but not CD8+ T cells, with evidence supporting an immunoregulatory role. Research Question: To understand the relationship between vitamin D, lung AAT levels and T lymphocytes further we investigated whether TGF-β is required as a co-factor for 1,25(OH)2D3-induced upregulation of AAT by vitamin D in CD8+ T cells in vitro and correlated circulating vitamin D levels with lung AAT levels in vivo. Results: 1,25(OH)2D3 in combination with TGF-β1 increased AAT expression by CD8+ T cells, as well as VDR and RXRα gene expression, which may partly explain the requirement for TGF-β. CD4+ T cells may also require autocrine stimulation with TGF-β as a co-factor since 1,25(OH)2D3 was associated with increased TGF-β bioactivity and neutralisation of TGF-β partially abrogated 1,25(OH)2D3-induced SERPINA1 gene expression. Neither CD4+ nor CD8+ T cells responded to the circulating vitamin D precursor, 25-hydroxyvitamin D3 for induction of SERPINA1, suggesting that local generation of 1,25(OH)2D3 is required. Transcriptional gene profiling studies previously demonstrated that human bronchial epithelial cells rapidly increased TGF-β2 gene expression in response to 1,25(OH)2D3. Here, human epithelial cells responded to precursor 25(OH)D3 to increase bioactive TGF-β synthesis. CD8+ T cells responded comparably to TGF-β1 and TGF-β2 to increase 1,25(OH)2D3-induced AAT. However, CD8+ T cells from adults with AAT-deficiency, homozygous for the Z allele of SERPINA1, were unable to mount this response. AAT levels in the airways of children with asthma and controls correlated with circulating 25(OH)D3. Conclusions: Vitamin D increases AAT expression in human T cells and this response is impaired in T cells from individuals homozygous for the Z allele of SERPINA1 in a clinic population. Furthermore, a correlation between circulating vitamin D and airway AAT is reported. We propose that vitamin D-induced AAT contributes to local immunomodulation and airway health effects previously attributed to vitamin D.

An audit of the impact of Covid-19 pandemic on the emotional wellbeing of children and parents with problematic severe asthma

Abstract: COVID-19 pandemic and the associated redeployment of healthcare infrastructure had a significant impact on normal services. Amongst a cohort with severe asthma children and young persons, attending a regional service, this questionnaire explored the impact of the pandemic and associated lockdown on emotional well-being. Our findings suggest that there were significant anxieties associated with the ability to access primary and secondary care services, medication during the pandemic – lockdown, as well as the psychological impact of social distancing and missing school work for this cohort. There was a common perception that this had adversely impacted their asthma control, although this was not clinically correlated. Our results indicate the need for health care providers to be aware of the psychological impact on the emotional wellbeing of the pandemic and offer appropriate help and counselling as needed. A correlation with deteriorating asthma control may need to be explored.

Fifteen-minute consultation: A structured approach to children with parapneumonic effusion and empyema thoracis

Abstract: Parapneumonic effusion is defined as the accumulation of pleural fluid associated with lung infection/pneumonia. Parapneumonic effusions can be uncomplicated or complicated. They are caused by the spread of infection and inflammation to the pleural space, and can develop into empyema thoracis—frank pus in the pleural space. Chest radiograph and thoracic ultrasound are the key imaging modalities for the diagnosis of parapneumonic effusion. Management aims are reducing inflammation and bacteria in the pleural cavity, and enabling full lung expansion. Broad-spectrum intravenous antibiotics, with the addition of chest tube drainage and fibrinolytic therapy for larger collections, are the mainstays of management. This article provides a clear, evidence-based and structured approach to the assessment and management of parapneumonic effusion/empyema thoracis in children and young people.