Severe asthma continues to be a significant cause of morbidity in children. Despite optimised standard therapy, many children remain symptomatic with subsequent impact on their quality of life and increased healthcare utilisation [1]. Children with ongoing poorly controlled asthma despite maximally prescribed treatment are identified as having problematic severe asthma [2]. Those whose poor control is due to modifiable factors including poor adherence to medications, continued exposure to allergens, social issues and psychological factors have difficult asthma. Severe therapy-resistant asthma is the term used for those with persistent symptoms despite attention to the basics of asthma management [3]. In children with problematic severe asthma, differentiating difficult asthma from severe therapy-resistant asthma is vital as correction of modifiable factors in patients with difficult asthma may result in improved symptom control and limit further investigations and exposure to expensive medications with potentially significant side effects. We have demonstrated that a structured outpatient nurse-led assessment that addresses the basics of asthma management leads to long-term benefits [1, 4]. The basics include confirming the diagnosis, ensuring correct inhaler technique, monitoring adherence, minimising allergen and smoke exposure, and assessing psychosocial factors. This involves nurse-led hospital, home and school visits, and a multidisciplinary evaluation. The assessment has been described in full previously [4]. Only once these factors have been addressed are children classified as having severe therapy-resistant asthma and consideration given to further assessments and add-on therapies such as omalizumab. Despite this rigorous assessment process, a small number of cases remain perplexing and cause concern, particularly when reported symptoms are discrepant with objective measures.

Little is known about adherence to inhaled corticosteroids (ICS) in preschool children with troublesome wheeze. Children with aeroallergen senitization, or those reporting multiple trigger wheeze (MTW), are more likely to respond to ICS. We hypothesized that adherence to ICS and symptom control are only positively related in atopic children, or those reporting MTW. Patients aged 1 to 5 years with recurrent wheeze prescribed ICS were recruited from a tertiary respiratory clinic. Clinical phenotype and aeroallergen senitization were determined, and adherence assessed using an electronic monitoring device (Smartinhaler). Symptom control (test for respiratory and asthma control in kids [TRACK]), quality of life (PACQLQ), airway inflammation (offline exhaled nitric oxide) were assessed at baseline and follow‐up. Forty‐eight children (mean age 3.7 years; SD, 1.2) were monitored for a median of 112 (interquartile range [IQR], 91‐126) days. At baseline n = 29 reported episodic viral wheeze and n = 19 reported MTW. Twenty‐four out of 48 (50%) wheezers had suboptimal ICS adherence (<80%). Median adherence was 64% (IQR, 38‐84). There was a significant increase in TRACK and PACQLQ in the group as a whole, unrelated to adherence. In subgroup analysis only atopic wheezers with moderate or good adherence ≥ 60% had a significant increase in TRACK. There was no relationship between clinical phenotype, and adherence or TRACK. In this pilot study, overall adherence to ICS was suboptimal and was positively related to symptom control in atopic wheezers only. Assessments of adherence are important in preschool troublesome wheezers before therapy escalation to help identify those with an ICS responsive phenotype.

Background: Nutrient deficiency after malabsorptive bariatric procedure is a common phenomenon. The study aims to determine the prevalence of nutritional insufficiencies (specific with Ascorbic acid, Cobalamin, calciferol and calcium) in obese population opting for One Ananstomosis Gastric Bypass surgery (OAGB), and also to understand the association of these nutrients with change in Body Mass Index (BMI) after the surgery. Methods: One hundred fifty subjects comprising males and females aged 20-60 years were randomly selected at a bariatric center in India. Subjects belonged to both grade III and grade II obesity. Plasma aa, serum vitB12, serum VitD3 and serum calcium concentrations were prospectively assessed at 0m, 3m, and 6m of surgery through high-performance liquid chromatography. Result: The values of nutrients beyond the standard levels are considered as deficiency. Both follow up values showed a significant increase in cobalamin, Calciferol, and ascorbic acid levels compared to baseline data. Conclusion: Nutrition depletion and deficiency are often seen in post bariatric cases. The contributing factors included high BMI, food intolerance, and non-adherence to supplements and correct dietary regimens. With the correction of weight and comorbidities, the levels also showed a stable and positive level. Bangladesh Journal of Medical Science Vol. 22 No. 03 July’23 Page : 695-708

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IntroductionBoth exhaled nitric oxide (FeNO), a non-invasive marker of eosinophilic airway inflammation, and lung clearance index (LCI), an effort independent assessment of distal airway function, are increased in pre-school children with multiple trigger wheezing (Sonnappa JACI 2010;126:519–26). However, whether there is any relationship between the two measures is unknown. We hypothesised that FeNO and LCI are positively related in pre-school children with a range of respiratory symptoms and this relationship would be strongest in pre-school wheeze.MethodsPatients aged between 2 and 6 years were recruited from the paediatric respiratory department at our tertiary centre. FeNO was measured using the offline technique (Niox Mino, Aerocrine AB, Sweden) and LCI was measured using the multiple breath washout technique (Sulphur hexafluoride tracer gas, photoacoustic gas analyser (Innocor, Innovision, Denmark)).Results19 children (median age 4.2, range 2.7–5.8 years) had assessments of both FeNO and LCI on the same day. Respiratory diagnoses were: multiple trigger wheeze (MTW) n=10, episodic viral wheeze (EVW) n=5, cough n=1, recurrent infections n=1, obliterative bronchiolitis (OB) n=1, sleep disordered breathing n=1. A significant correlation was found between FeNO and LCI, in pre-school children with respiratory symptoms (Spearman correlation coefficient r=0.5, p=0.02) (figure 1). When the MTW and EVW groups were compared, there was no correlation between FeNO and LCI in EVW, but there was a significant relationship in MTW (r=0.6, p=0.05).Abstract P88 Figure 1Relationship between offline exhaled nitric oxide (FeNO) and lung clearance index (LCI). MTW: multiple trigger wheeze.ConclusionsThere was a positive relationship between FeNO and LCI in pre-school children with a range of respiratory symptoms. The relationship was strongest in those with recurrent multiple trigger wheeze. These data provide further evidence for different pathophysiologies in MTW and EVW, implying the need for different treatment approaches.