BACKGROUND:The management of severe asthma with biologics has become more complex involving multidisciplinary team meetings. Artificial intelligence has been proposed as an adjunct to aid healthcare professionals in other areas of the medical field. OBJECTIVE:Our aim is to determine if there is a role for artificial intelligence, as an adjunct to the severe asthma multidisciplinary team meeting, to offer improved consistency and efficiency in biologic prescribing. METHODS:This is a retrospective, unblinded single-centre, multisite cohort study including patients with uncontrolled severe GINA defined stage 5 asthma for biologic consideration who were biologic naïve. They were discussed at joint multidisciplinary team meetings between secondary care referral centres in the health board NHS Tayside, Scotland between January 2024 and August 2025. The multidisciplinary team biologic decisions were compared to five large language model recommendations (ChatGPT, Gemini, CoPilot, PerplexityAI and DeepSeek) using Cohen's kappa with the multidisciplinary team meeting as the reference. RESULTS:Among 114 patients, the mean (SD) age was 54·5 (15·0) years, asthma control questionnaire score 2·98 (1·1), annualised exacerbation rate 5·21 (2·1). Multidisciplinary team decisions and artificial intelligence recommendations showed poor agreement (κ = 0·143-0·213). Agreement between artificial intelligence models was weak to moderate (κ = 0·348-0·586) with frequent decision making errors identified with all artificial intelligence models. CONCLUSION:At the time of analysis, artificial intelligence models show poor concordance highlighting their unsuitability as either a standalone or adjunctive decision maker for biologic therapy. Multidisciplinary team meetings remain the reference standard.
BACKGROUND:Biologic therapies have transformed the management of severe asthma, yet many patients in routine care remain symptomatic. Most real-world data originate from tertiary centers and may not reflect broader healthcare delivery. OBJECTIVE:To describe disease control, exacerbations, adherence, comorbidities, phenotypes, and care gaps in adults with severe asthma managed in French non-academic hospitals in the biologic's era. METHODS:FASE2-CPHG was a national, multicenter, cross-sectional study conducted between 2022 and 2023 in French non-academic hospitals. Adults with GINA 2022 Step 5 asthma were consecutively included during routine care. Physicians completed electronic case report forms and patients completed questionnaires assessing asthma control (ACT), adherence (Girerd score), anxiety and depression (HADS), and physical activity (Ricci & Gagnon's questionnaire). Clinical characteristics, biomarkers, imaging, exacerbations, and treatments including biologics were recorded. RESULTS:Among 970 patients (mean age 54.5 ±15.8 years; 66.3% female), 71.2% were receiving biologic therapy. Despite these treatments, 59.8% had partially controlled or uncontrolled asthma according to ACT questionnaire. Globally, 62.6% experienced at least one exacerbation in the previous year. The median annual exacerbation rate was 1 (IQR 0-3). Only 31.6% of patients reported full adherence, whereas 88.7% were considered adherent by physicians. Anxiety and depressive symptoms were present in 45.6% and 24.6% of patients, respectively. Biologic therapy was prescribed in 71.2% of patients with omalizumab used in most case (41.2%). The mean duration of the ongoing treatment with biologics was 2.9 years (±5.1). CONCLUSIONS:In routine non-academic hospital practice, biologics are widely implemented but a majority of patients remains uncontrolled. Major care gaps include unrecognized poor adherence, high psychological, metabolic and ENT comorbidity burden, and incomplete optimization of inhaled therapy. Addressing these gaps may yield gains comparable to the introduction of new biologic agents.
BACKGROUND:The triglyceride-glucose (TyG) index is a new alternative marker for insulin resistance and metabolic dysfunction, which has recently been linked to lung health. However, the link among the TyG index, type 2 (T2) inflammation, and asthma is largely unexplored. OBJECTIVES:To explore clinical, inflammatory characteristics and exacerbations in patients with asthma grouped by the TyG index with or without T2 inflammation. METHODS:This was a prospective cohort study with 12-month follow-up based on the Australasian Severe Asthma Network. Patients with stable asthma were divided into the TyGlow and TyGhigh groups by the 75th percentile values of the TyG index. Subgroups were analyzed based on T2 status. All participants with stable asthma (n = 626) underwent multidimensional assessment and sputum induction. Univariate and multivariable negative binomial regression analyses were used to examine the relationship between asthma exacerbations and TyG index with or without T2 inflammation. RESULTS:Patients with asthma in the TyGhigh group (n = 156) had higher body mass index, worse metabolic function and airway obstruction, more comorbidities including diabetes and metabolic syndrome, and increased risk of exacerbations independent of T2 inflammation, compared with the TyGlow group (n = 470). Furthermore, the TyGhigh T2low group was at significantly increased risk of moderate-to-severe exacerbations (adjusted incidence rate ratio [IRR] = 2.54, 95% confidence interval [CI] = [1.56, 4.15], P < .001), emergency visits (adjusted IRR = 7.88, 95% CI = [2.71, 22.92], P < .001), and unscheduled visits (adjusted IRR = 2.87, 95% CI = [1.65, 4.98], P < .001). CONCLUSIONS:The TyG index is a promising biomarker of asthma exacerbations, highlighting the clinical relevance of assessing the TyG index in asthma management.
BACKGROUND:Perioperative anaphylaxis (POA), an acute circulatory failure usually IgE-mediated, remains a significant cause of anesthesia-related deaths. Because early recognition of this life-threatening condition is critical, we previously investigated the association of clinical characteristics with IgE-mediated allergy and showed that early cutaneous vasoconstriction was pathognomonic of IgE-mediated anaphylaxis. OBJECTIVE:To evaluate whether early cutaneous vasoconstriction phenotype is associated with an increased risk of fatal/near-fatal POA and analyze the mechanisms leading to poor outcomes. METHODS:This is a prespecified analysis of a retrospective observational cohort study conducted at 2 academic medical centers. Included in the study were adults diagnosed with IgE-mediated anaphylaxis (grades III and IV according to the modified Ring and Messmer scale) in the main analysis and those with a fatal or near-fatal outcome. IgE-mediated anaphylaxis successfully treated with mechanical circulatory support was defined as near-fatal. RESULTS:Of 72 included patients with IgE-mediated anaphylaxis (grade III: 65 [90.3%] and grade IV: 7 [9.7%]), 45 (62.5%) and 27 (37.5%) were, respectively, categorized in the miscellaneous (early or late cutaneous vasodilation or lack of cutaneous signs) and early cutaneous vasoconstriction groups. Six fatal or near-fatal cases (grade III: 4 and grade IV: 2) were exclusively reported in the early cutaneous vasoconstriction group. Early cutaneous vasoconstriction phenotype was associated with fatal/near-fatal outcomes. Fatal/near-fatal outcomes occurred in 22.2% of patients with cutaneous vasoconstriction (n = 6 of 27) while in none of those from the miscellaneous group (n = 0 of 45) (absolute risk difference: 22.2% [95% confidence interval: 8.2-40.8]). Fatal and near-fatal cases accounted for 18.5% (n = 5 of 27) and 3.7% (n = 1 of 27) of cases, respectively. Early cutaneous vasoconstriction was always associated with bradycardia (median [interquartile range]: 46 [38-57] beats/min) in the 6 fatal/near-fatal cases. A symptomatic treatment, disregarding the pathophysiological mechanisms of POA, might have contributed to poor outcomes. CONCLUSIONS:POA exhibiting early cutaneous vasoconstriction was associated with an increased risk of fatal/near-fatal outcomes. Early cutaneous vasoconstriction and bradycardia likely reflect greater initial severity, owing to profound hypovolemia. This highlights the importance of recognizing this lesser-known phenotype. Further research is warranted.
BACKGROUND:Type 2 (T2)-low asthma is often less responsive to inhaled corticosteroids (ICS); however, optimal controller strategies for this phenotype remain inadequately defined. OBJECTIVE:To evaluate whether long-acting muscarinic antagonists (LAMA) are non-inferior to ICS in patients with T2-low mild asthma. METHODS:In this multicenter, pragmatic, randomized, open-label, crossover trial, adults with T2-low mild asthma (blood eosinophils <300/μL, and either FeNO <25 ppb or sputum eosinophils <3%) were randomized 1:1 to 6 months of ICS followed by 6 months of LAMA, or vice versa. The primary outcome was a composite treatment-success endpoint. Non-inferiority was established if the lower bound of the 95% confidence interval (CI) for the success rate difference was greater than -10 percentage points. RESULTS:Among 150 randomized patients, 89 completed both phases (per-protocol population). Treatment success was 7.9 percentage points higher with LAMA (95% CI, -2.9 to 18.8; P<0.001), consistent with two intention-to-treat analyses (risk differences, 4.1-4.2 percentage points). In another intention-to-treat analysis where all uncompleted phases were considered as failures, non-inferiority was not established (-3.3 percentage points; 95% CI, -11.3 to 4.5), though it was supported under a non-responder imputation approach for missing data (one-sided P = 0.020). The favorable effect was more pronounced in patients aged <65 years. Exacerbation rates did not differ significantly, and symptom control and lung function remained stable across both phases. CONCLUSION:In patients with T2-low mild asthma, LAMA monotherapy may be non-inferior to ICS and may be considered an alternative controller option for selected patients.
Eosinophilic gastrointestinal disorders encompass chronic, immune-mediated disorders indicative of eosinophil infiltration and inflammation causing a range of gastrointestinal symptoms. Eosinophilic gastrointestinal disorders are subdivided into the part of the gastrointestinal tract that is involved, including eosinophilic esophagitis, eosinophilic gastritis, eosinophilic enteritis, and eosinophilic colitis. Treatment for eosinophilic gastrointestinal disorders can vary widely, and treatment modalities include dietary intervention, drugs, and endoscopy-based dilation therapy. With these wide range of therapeutic options, shared decision-making with the patient is important for finding the right treatment for each individual patient. In this review, treatment modalities for eosinophilic gastrointestinal disorders will be summarized for both pediatric and adult populations. This review will focus on shared decision-making aspects in treating eosinophilic gastrointestinal disease with balancing efficacy, risks, patient preference, and quality of life.
The American Academy of Allergy, Asthma & Immunology and the American College of Allergy, Asthma, & Immunology Joint Task Force on Practice Parameters (JTFPP) produces guidelines applying the Grading of Recommendations, Assessment, Development and Evaluations framework of evidence appraisal. Grading of Recommendations, Assessment, Development and Evaluations recommendations can be strong or conditional and in favor or against a specific action. Strong recommendations may serve as quality measures. Conditional recommendations serve as a navigational signal for shared decision making. The mission of the American Academy of Allergy, Asthma & Immunology Measures Stewardship Committee is to evaluate the quality of care provided to patients in Allergy-Immunology. Clear, accurate, and just quality measurement programs are important not only for clinical care but also for financial payments that exist in the United States based on these measures. Allergy-Immunology has yet to secure a "home" in modern quality measures reporting, because redesigned public and private reimbursement frameworks have not included dedicated measures for our specialty. The goals of this report were to (1) link Joint Task Force on Practice Parameters guideline recommendations with existing quality measures and (2) identify opportunities for the development, prioritization, validation, and implementation of quality measures that are both patient-centered and responsive to the needs of Allergy-Immunology specialists.
Eosinophilic gastrointestinal disorders (EGIDs) are chronic, immune-mediated conditions characterized by eosinophil-predominant inflammation of the gastrointestinal tract, encompassing eosinophilic esophagitis (EoE) and non-EoE EGIDs (eosinophilic gastritis, gastroenteritis, enteritis, and colitis). Over the past 3 decades, their clinical recognition has increased substantially, driven by rising incidence and prevalence-particularly for EoE, which is no longer considered rare in Western countries. In contrast, non-EoE EGIDs remain uncommon and incompletely characterized. Data reveal significant geographic variation and evolving epidemiologic patterns in EGIDs, including rapidly increasing EoE rates in East Asia. Early-life environmental exposures, gene-environment interactions, and Westernization-associated factors may contribute to these trends. EoE is typically chronic and progressive, with diagnostic delay associated with fibrostenotic complications, thus highlighting the importance of early recognition and maintenance therapy. Although non-EoE EGIDs were historically considered episodic, emerging data indicate that persistent disease is common, especially in pediatric populations. Across the spectrum, atopic comorbidities are frequent, and psychological burden is substantial. Together, these findings highlight EGIDs as chronic, evolving disorders with increasing prevalence that require earlier recognition, and long-term monitoring and management. Coordinated research initiatives are needed to close major gaps in diagnostic tools and thresholds, natural history, and long-term care.
Schools are a key point of intervention for child health. Children spend most of their days in school, and school nurses are well trained in the acute management of many childhood chronic diseases. The approach to asthma has changed significantly over time, with updates to inhaled corticosteroid use, the use of single inhalers for both relievers and controllers, and the increasing use of asthma biologics for managing severe asthma. Asthma specialists can play an important role in providing timely updates for school nurses about ongoing changes in overall asthma management. The purpose of this review is to summarize the evolution of our urban-centered school-based asthma program to one that has expanded into many school districts across Colorado, including rural communities, by applying principles of implementation science. We will share steps that we took to grow and scale this program as well as lessons learned during dissemination to additional school districts in Colorado. An effective school nurse-clinician interaction sets up a strong infrastructure for identifying children and adolescents who are not receiving optimal chronic disease care. Such efforts can leverage existing partnerships between schools and the health care system to improve the network of care for children with poorly controlled asthma.
IgE-mediated food allergy and eosinophilic esophagitis (EoE) represent distinct yet interconnected manifestations of food-induced immune dysregulation. Rather than separate entities, emerging evidence supports a model that is on a continuum, in which clinical phenotypes are determined by antigen exposure patterns, dose, chronicity, and individual immune responses. This relationship has critical implications for food allergy immunotherapy, particularly oral immunotherapy. Among children with IgE-mediated food allergy, EoE prevalence is nearly 100-fold higher than the general population at 4.7%. During oral immunotherapy, gastrointestinal symptoms are common, with confirmed EoE developing in 1% to 10% of participants. Mechanistically, antigen avoidance favors IgE-mediated responses through T follicular helper cells, whereas sustained exposure promotes TH2-driven esophageal inflammation via pathogenic effector TH2 cells. Regulatory T-cell dysfunction appears central to this phenotypic switching. Clinical management requires risk stratification, systematic monitoring strategies, and individualized protocols that balance desensitization benefits against esophageal inflammation risks. Future directions include noninvasive diagnostic biomarkers, biologic therapies, and evidence-based prevention strategies. Understanding the food allergy-EoE continuum is essential for optimizing safety and efficacy of food allergen immunotherapy while minimizing complications.
