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- Adherence to treatment in allergic rhinitis during the pollen season in Europe: A MASK‐air StudyPublication . Bousquet, Jean; Amaral, RitaAdherence to rhinitis treatment has been insufficiently assessed. We aimed to use data from the MASK-airmHealth app to assess adherence to oral antihistamines (OAH), intra-nasal corticosteroids (INCS) or azelastine-fluticasone inpatients with allergic rhinitis. We included regular European MASK-air users with self-reported allergic rhinitis and reporting at least 1 day of OAH,INCS or azelastine-fluticasone. We assessed weeks during which patients answered the MASK-air questionnaire on all days. Werestricted our analyses to data provided between January and June, to encompass the pollen seasons across the different assessedcountries. We analysed symptoms using visual analogue scales (VASs) and the combined symptom-medication score (CSMS),performing stratified analyses by weekly adherence levels. Medication adherence was computed as the proportion of days inwhich patients reported rhinitis medication use. Sensitivity analyses were performed considering all weeks with at most 1 day ofmissing data and all months with at most 4 days of missing data. We assessed 8212 complete weeks (1361 users). Adherence (use of medication > 80% days) to specific drug classesranged from 31.7% weeks for azelastine-fluticasone to 38.5% weeks for OAH. Similar adherence to rhinitis medication was foundin users with or without self-reported asthma, except for INCS (better adherence in asthma patients). VAS and CSMS levelsincreased from no adherence to full adherence, except for INCS. A higher proportion of days with uncontrolled symptoms was observed in weeks with higher adherence. In full adherence weeks, 41.2% days reported rhinitis co-medication. The sensitivityanalyses displayed similar results. A high adherence was found in patients reporting regular use of MASK-air. Different adherence patterns werefound for INCS compared to OAH or azelastine-fluticasone that are likely to impact guidelines.
- Adult asthma scores—development and validation of multivariable scores to identify asthma in surveysPublication . Sá-Sousa, Ana; Pereira, Ana Margarida; Almeida, Rute; Araújo, Luís; Couto, Mariana; Jacinto, Tiago; Freitas, Alberto; Bousquet, Jean; Fonseca, João A.One of the questions in epidemiology is the identification of adult asthma in studies. To develop and validate multivariable scores for adult asthma identification in epidemiological studies and to explore cutoffs to rule in/rule out asthma, compared with asthma diagnosed by a physician after clinical examination and diagnostic tests, blinded to the self-administered questions. We analyzed data (n = 711 adults) from a nationwide population-based study. The predictors were self-administered questions identified in a literature review (the Adult Asthma Epidemiological Score [A2 score]) and from the Global Allergy and Asthma Network of Excellence (GA2LEN) questionnaire (the GA2LEN Asthma Epidemiological Score [GA2LEN score]). Scores were developed using exploratory factor analysis. Internal consistency, discriminative power, and diagnostic accuracy were assessed. The A2 score comprises 8 questions (including “Did a physician confirm you had asthma?”) and the GA2LEN score comprises 6 questions (including “Have you ever had asthma?”). Both had high Cronbach α (0.89 and 0.85, respectively, for the A2 score and the GA2LEN score) and good area under the receiver-operating characteristic curve (90.4% and 89.0%). The scoring is the sum of positive answers. Asthma is present (rule in) for scores of 4 or more (specificity, 99.2%; PPV, 93.3% and 91.7%; accuracy, 89.4% and 87.4%, respectively, for the A2 score and the GA2LEN score). Asthma is excluded (rule out) for A2 scores of 0 to 1 and a GA2LEN score of 0 (sensitivity, 93.1%; NPV, 98.2% and 98.0%; accuracy 89.4% and 82.8%, respectively, for the A2 score and the GA2LEN score). These practical scores can be used to rule in/rule out asthma in epidemiological studies and clinical screening/triage settings. They may help physicians in primary care or other specialties to screen patients with asthma using a simple score with a high level of discrimination and to identify the best candidates to be referred for a diagnostic workup. Moreover, their use may contribute to reducing the inconsistencies of operational definitions of asthma across studies and surveys.
- Allergen sensitization associates with worse lung function parametersPublication . Gonçalves, I.; Pereira, A. M.; Jacinto, Tiago; Amaral, Rita; Fonseca, J. de Almeida Lopes daTo assess the association between the number of allergen sensitizations and lung function variables in individuals with airway symptoms. Methods. Retrospective study with all individuals who performed lung function and skin-prick tests at CUF-Porto (01/2011-06/2016). Six allergen groups were considered. % predicted Pre-Bronchodilator test (BD) and % change after BD were analysed for spirometry and plethysmography parameters. Results. A total of 1293 individuals were included, 54% (n = 698) adults and 69% (n = 891) with sensitization to ≥ 1 allergen group. % FEV1 was significantly higher and % change in FEV1 significantly lower in non-sensitized individuals. % sRaw was higher in polysensitized (vs non-sensitized). Conclusions. The presence of allergen sensitizations was significantly associated with worse key lung function parameters.
- Avaliação objetiva no diagnóstico de broncoconstrição induzida pelo exercícioPublication . Couto, Mariana; Jacinto, TiagoA broncoconstrição induzida pelo exercício (BIE) define -se como o aumento transitório da resistência das vias aéreas resultante da obstrução brônquica que ocorre após esforço físico. É uma entidade clínica muito frequente, que importa diagnosticar corretamente de forma a prevenir a resposta broncoconstritora ao esforço, de modo a que esta não constitua restrição à escolha de uma atividade física ou limitação ao nível do desempenho desportivo. A história clínica pode ser extremamente sugestiva, porém, são frequentes tanto situações de sobrediagnóstico de asma como de subdiagnóstico de BIE. Assim sendo, e face à importância do diagnóstico exato, pretende -se com o presente artigo apresentar os exames complementares no diagnóstico de BIE, abordando a sua utilidade e aplicabilidade.
- Book review: non-Invasive ventilation made simplePublication . Jacinto, TiagoNon-invasive ventilation (NIV) is well established and increasingly used in routine clinical practice, either in the management of acute respiratory failure, where it has resulted in improved survival and reduced number of complications or in weaning from invasive ventilation in intensive care or high-dependency units. However, some concepts and techniques of NIV may be difficult to grasp for students or for unexperienced healthcare professionals.
- Comparison of allergic rhinitis treatments on patient satisfaction: A MASK-air and EAACI Methodological Committee ReportPublication . Bousquet, Jean; Amaral, RitaSatisfaction with treatments may affect medication adherence and use patterns, including the use of comedication. We aimed to compare different medications for allergic rhinitis (AR) on (i) patients' satisfaction and (ii) co-medication use frequency. We assessed data from the mHealth app MASK-air. We evaluated days on which users with self-reported AR had used—alone or in co-medication—intranasal corticosteroids (INCS), intranasal antihistamines (INAH), fixed combinations of INAH+INCS, or oral antihistamines (OAH). We built multivariable regression models to compare these different AR medication classes (as well as individual medications) on their (i) treatment satisfaction levels (measured using a specific daily visual analogue scale [‘VAS satisfaction’]) and (ii) odds of being used in co-medication. We assessed 28,177days reported by 1691 MASK-air users. For all medication classes, co-medication usage was associated with lower treatment satisfaction. When used in monotherapy, OAH were associated with lower VAS satisfaction than INCS (−1.7 points; 95% CI=–2.7; –0.7) or INAH+INCS (−2.1 points; 95% CI=–3.5; –0.7). INCS displayed higher odds of being used in co-medication than OAH (OR=1.3; 95% CI=1.0; 1.6) or INAH+INCS (OR=1.3; 95% CI=0.8; 1.8). When comparing individual intranasal medications, fluticasone furoate and fluticasone propionate tended to be more frequently used in co-medication. Among individual OAH, desloratadine and rupatadine were associated with higher satisfaction, while fexofenadine was more frequently used in co-medication. Using patient-reported data, we evaluated different medication classes and treatments in terms of satisfaction and co-medication frequency. These results provide key insights into the acceptability of AR treatments and will contribute to future treatment guidelines.
- Comparison of hypothesis- and data-driven asthma phenotypes in NHANES 2007–2012: the importance of comprehensive data availabilityPublication . Amaral, Rita; Pereira, Ana M.; Jacinto, Tiago; Malinovschi, Andrei; Janson, Christer; Alving, Kjell; Fonseca, João A.Half of the adults with current asthma among the US National Health and Nutrition Examination Survey (NHANES) participants could be classified in more than one hypothesis-driven phenotype. A data-driven approach applied to the same subjects may allow a more useful classification compared to the hypothesis-driven one. To compare previously defined hypothesis-driven with newly derived data-driven asthma phenotypes, identified by latent class analysis (LCA), in adults with current asthma from NHANES 2007–2012. Adults (≥ 18 years) with current asthma from the NHANES were included (n = 1059). LCA included variables commonly used to subdivide asthma. LCA models were derived independently according to age groups: < 40 and ≥ 40 years old. Two data-driven phenotypes were identified among adults with current asthma, for both age groups. The proportions of the hypothesis-driven phenotypes were similar among the two data-driven phenotypes (p > 0.05). Class A < 40 years (n = 285; 75%) and Class A ≥ 40 years (n = 462; 73%), respectively, were characterized by a predominance of highly symptomatic asthma subjects with poor lung function, compared to Class B < 40 years (n = 94; 25%) and Class B ≥ 40 years (n = 170; 27%). Inflammatory biomarkers, smoking status, presence of obesity and hay fever did not markedly differ between the phenotypes. Both data- and hypothesis-driven approaches using clinical and physiological variables commonly used to characterize asthma are suboptimal to identify asthma phenotypes among adults from the general population. Further studies based on more comprehensive disease features are required to identify asthma phenotypes in population-based studies.
- Concepts for the Development of Person-Centered, Digitally Enabled, Artificial Intelligence–Assisted ARIA Care Pathways (ARIA 2024)Publication . Bousquet, Jean; Amaral, Rita; Amaral, RitaThe traditional healthcare model is focused on diseases (medicine and natural science) and does not acknowledge patients’ resources and abilities to be experts in their own lives based on their lived experiences. Improving healthcare safety, quality, and coordination, as well as quality of life, is an important aim in the care of patients with chronic conditions. Person-centered care needs to ensure that people’s values and preferences guide clinical decisions. This paper reviews current knowledge to develop digital care pathways for rhinitis and asthma multimorbidity and digitally enabled, person-centered care.1 It combines all relevant research evidence, including the so-called real-world evidence, with the ultimate goal to develop digitally enabled, patient-centered care. The paper includes Allergic Rhinitis and its Impact on Asthma (ARIA), a 2-decade journey, Grading of Recommendations, Assessment, Development and Evaluation (GRADE), the evidence-based model of guidelines in airway diseases, mHealth impact on airway diseases, .From guidelines to digital care pathways, Embedding Planetary Health, Novel classification of rhinitis and asthma, Embedding real-life data with population-based studies, The ARIA-EAACI (European Academy of Allergy and Clinical Immunology) strategy for the management of airway diseases using digital biomarkers, Artificial intelligence, The development of digitally enabled, ARIA person-centered care, and The political agenda. The ultimate goal is to propose ARIA 2024 guidelines centered around the patient to make them more applicable and sustainable.
- Control of allergic rhinitis and asthma test for children (CARATkids): A systematic review and meta-analysis of its measurement propertiesPublication . Didi, Hadla Sami El; Pereira, Ana Margarida; Jácome, Cristina; Amaral, Rita; Wandalsen, Gustavo F.; Emons, Joyce; Grutta, Stefania La; Cilluffo, Giovanna; Batmaz, Sehra Birgül; Linhares, Daniela; Sole, Dirceu; Pinto, Bernardo Sousa; Fonseca, João Almeida; Vieira, Rafael José; Amaral, RitaControl of Allergic Rhinitis and Asthma Test for Children (CARATkids) is the first patient-reported outcome measure (PROM) designed to assess both allergic rhinitis and asthma simultaneously in children aged 6 to 12 years. CARATkids has been validated in several languages and countries, highlighting the need for a review of its psychometric properties. This study aims to evaluate the measurement properties of CARATkids. This systematic review follows PRISMA and COSMIN guidelines. A systematic search was performed across three databases (Ovid/MEDLINE, Web of Science, and Scopus in October 2023, updated in June 2025). We included studies focused on the development, cultural adaptation, or validation of CARATkids, as well as studies comparing CARATkids with other PROMs. We evaluated the quality of CARATkids development, the methodological quality of primary studies, the overall rating, and the certainty of evidence for each CARATkids measurement property and performed a meta-analysis of its measurement properties. Our search retrieved 193 results. We included nine studies. CARATkids displayed sufficient content validity. Regarding internal consistency, we found a meta-analytical Cronbach alpha of 0.81 (95% CI = 0.79; 0.83). CARATkids displayed sufficient reliability (meta-analytical intraclass correlation coefficient 0.86 [95% CI = 0.61; 0.96]). The minimal clinically important difference was 2.76. Construct validity had sufficient evidence for most correlations, with absolute meta-analytical Spearman coefficients from 0.37 to 0.71. Responsiveness showed strong correlations between CARATkids and most outcome measurement instruments. These findings support CARATkids as a suitable tool for assessing asthma and allergic rhinitis in children aged 6 to 12 years who present both conditions simultaneously.
- Control of allergic rhinitis and asthma test: a systematic review of measurement properties and COSMIN analysisPublication . Vieira, Rafael José; Sousa-Pinto, Bernardo; Cardoso-Fernandes, António; Jácome, Cristina; Portela, Diana; Amaral, Rita; Sá-Sousa, Ana; Pereira, Ana Margarida; Bousquet, Jean; Fonseca, João AlmeidaThe Control of Allergic Rhinitis and Asthma Test (CARAT) is a patient-reported outcome measurement (PROM) assessing the control of asthma and allergic rhinitis (AR) at a 4 week interval. This systematic review aimed to evaluate the measurement properties of CARAT. Following PRISMA and COSMIN guidelines, we searched five bibliographic databases and retrieved studies concerning the development, assessment of properties, validation, and/or cultural adaption of CARAT. The studies' methodological quality, the quality of measurement properties, and the overall quality of evidence were assessed. We performed meta-analysis of CARAT measurement properties. We included 16 studies. Control of Allergic Rhinitis and Asthma Test displayed sufficient content validity and very good consistency (meta-analytical Cronbach alpha = 0.83; 95% CI = 0.80–0.86;I2 = 62.6%). Control of allergic rhinitis and Asthma Test meta-analytical intraclass correlation coefficient was 0.91 (95% CI = 0.64–0.98;I2 = 93.7%). It presented good construct validity, especially for correlations with Patient-reported outcome measures assessing asthma (absolute Spearman correlation coefficients range = 0.67–0.73; moderate quality of evidence), and good responsiveness. Its minimal important difference is 3.5. Overall, CARAT has good internal consistency, reliability, construct validity and responsiveness, despite the heterogeneous quality of evidence. Control of Allergic Rhinitis and Asthma Test can be used to assess the control of asthma and AR. As first of its kind, this meta-analysis of CARAT measurement properties sets a stronger level of evidence for asthma and/or AR control questionnaires.