Nederlands Astmacentrum Davos

<bold>Background:</bold> Severe asthma management remains challenging. Despite the availability of biologicals, effective add-on corticosteroid-sparing strategies remain important for patients with severe asthma. This study aims to evaluate the corticosteroid-sparing effects of alpine altitude climate treatment (AACT) in patients with uncontrolled severe asthma. <bold>Methods:</bold> In this prospective cohort, clinical data from Dutch patients with uncontrolled severe asthma were collected between 2018-2022, before and after AACT. Outcome measures included ability to stop maintenance oral corticosteroids (OCS), OCS dose reduction, change in asthma control (ACQ6) and health-related quality of life (AQLQ). <bold>Results:</bold> At baseline, 42% of 375 patients (70% female, 35% late-onset, median(IQR) age 49(20)) were using maintenance OCS, 26% were using a biological, while 27% of the patients had previously used a biological. Stopping maintenance OCS was possible in 52% of patients, irrespective of current or previous biological use. Significantly reducing OCS dose (≥2.5 mg per day) was possible in another 32% of patients currently or previously using biologicals. AACT resulted in significantly improved asthma outcomes in the whole cohort median(IQR) ACQ 3.0 (1.2) to 1.5 (1.5) and AQLQ 4.0(1.3) to 5.5(1.3). <bold>Conclusion:</bold> This prospective cohort study demonstrates that non-pharmacological, multidisciplinary pulmonary rehabilitation in the alpine altitude climate (AACT) is an effective add-on corticosteroid-sparing treatment option, while resulting in improved asthma control for patients with uncontrolled severe asthma, irrespective of biological use.

<bold>Background:</bold> Fatigue is a major concern for patients with severe asthma and tied to poor asthma control. This study investigates the impact of multidisciplinary pulmonary rehabilitation in the alpine altitude climate (AACT) on fatigue and identifies factors contributing to persistent severe fatigue. <bold>Methods:</bold> 420 patients with severe, uncontrolled asthma, referred for AACT (2007- 2018), underwent a systematic assessment including: subjective fatigue (CIS-Fatigue), psychopathology (SCL90), asthma control (ACQ6), health-related quality of life (AQLQ), spirometry, FeNO, blood eosinophil counts, atopic status, oral corticosteroid (OCS) use, comorbidities, and exercise capacity. <bold>Results:</bold> At baseline, 91% of patients reported severe fatigue (CIS-F ≥36). Eleven weeks of AACT led to significant improvements in CIS-F (median(IQR) 50(11) to 27(21)) and ACQ6 (3.0(1.3) to 1.2(1.3)), and all conventional asthma outcomes. However, 27% of patients experienced persistent severe fatigue at the end of AACT, correlating with less improvement in asthma outcomes. Multivariable regression analysis identified daily OCS use, sleeping problems, higher baseline fatigue score, and older age as independent predictors of persistent severe fatigue. <bold>Discussion:</bold> This is the first major cohort study investigating the impact of rehabilitation on fatigue in severe asthma. It shows that multidisciplinary Alpine Altitude Climate Treatment results in recovered fatigue and improved asthma control in most patients. Maintenance OCS, sleeping problems, more fatigue at baseline, and older age predict persistent severe fatigue, emphasizing the need for targeted treatment strategies.

Currently available European Alpine Altitude Climate Treatment (AACT) programs combine the physical characteristics of altitude with the avoidance of environmental triggers in the alpine climate and a personalized multidisciplinary pulmonary rehabilitation approach. The reduced barometric pressure, oxygen pressure, and air density, the relatively low temperature and humidity, and the increased UV radiation at moderate altitude induce several physiological and immunological adaptation responses. The environmental characteristics of the alpine climate include reduced aeroallergens such as house dust mites (HDM), pollen, fungi, and less air pollution. These combined factors seem to have immunomodulatory effects controlling pathogenic inflammatory responses and favoring less neuro‐immune stress in patients with different asthma phenotypes. The extensive multidisciplinary treatment program may further contribute to the observed clinical improvement by AACT in asthma control and quality of life, fewer exacerbations and hospitalizations, reduced need for oral corticosteroids (OCS), improved lung function, decreased airway hyperresponsiveness (AHR), improved exercise tolerance, and improved sinonasal outcomes. Based on observational studies and expert opinion, AACT represents a valuable therapy for those patients irrespective of their asthma phenotype, who cannot achieve optimal control of their complex condition despite all the advances in medical science and treatment according to guidelines, and therefore run the risk of falling into a downward spiral of loss of physical and mental health. In the light of the observed rapid decrease in inflammation and immunomodulatory effects, AACT can be considered as a natural treatment that targets biological pathways.

La poesía de Lorca ha tenido una influencia enorme en la cultura literaria de la URSS, especialmente a partir de los años 60 a raíz del «deshielo» de Jruschov. En esta época, Lorca prácticamente personificaba toda la poesía española para la sociedad rusa y las traducciones del poeta al ruso crearon su propia corriente literaria de diálogo intercultural. &#x0D; El objetivo de esta investigación es estudiar dicho fenómeno a través del prisma de los cambios socioculturales en la Unión Soviética y demostrar cómo la recepción inicial de Lorca, en principio totalmente propagandística, se convierte con el paso de tiempo en una vía de inserción de las ideas que luchan contra la misma propaganda. También se estudia la aparición del «mito» durante el proceso de recepción, la tergiversación de la imagen del poeta y de los hechos de su vida vinculada con las características socioculturales del país y de la época de su recepción.

&#x0D; &#x0D; &#x0D; &#x0D; El propósito de este artículo, reside en mostrar y analizar, las metáforas más notables con las cuales el maestro dominico de vida espiritual Eckhart, transmite la reunión del alma humana creada y separada (existente) del Dios Creador, con lo Uno, o unidad esencial originaria, definida en su totalidad como Deidad. La atención se centra en alguno de sus sermones, donde se explican las alegorías del alma humana, la divinidad y la fusión o encuentro de ambas en la Deidad. Se trata de un recorrido interpretativo por elementos centrales y alegóricos de su mística nihilista y de su teología negativa, donde la única y última conclusión sostenible es que “Todo se hace Nada”.&#x0D; &#x0D; &#x0D; &#x0D; &#x0D;

A 6-week personalized integrative multidisciplinary treatment programme (PIM) was developed for children with difficult to treat AD who appeared unresponsive to treatment according to current guidelines. The aim of the present study was to identify clinical and psychosocial characteristics that predict long-term treatment success after PIM. Treatment was considered successful when there was a 75% reduction on the Self-Administered Eczema Area and Severity Index and/or little impact of AD on daily life, measured with the Children's Dermatology Life Quality Index (score ≤ 6), 6 months after the end of PIM. PIM is a personalized, integrative, multidisciplinary treatment programme with clearly defined goals and strategies, addressing atopic, paediatric, mental health comorbidities and general well-being, for children and adolescents aged 8- to 18 years. Multivariate logistic regression models were constructed using a backward selection procedure. Questionnaires were used to assess psychosocial characteristics; clinical data was extracted from medical records. In total, 79 children/adolescents with difficult to treat AD completed PIM and long-term treatment results were available for 74 children/adolescents. The majority (77%) of children/adolescents demonstrated long-term treatment success with PIM. Predictors of long-term treatment success (adjusted ORs) included maternal disease acceptance OR (95% CI) 1.84 (1.15-2.94). A group (23%) of mostly females OR (95% CI) 0.10 (0.02-0.54) with multiple somatic complaints OR (95% CI) 0.88(0.80-0.97), from families where the mother has anxiety for the use of topical corticosteroids OR (95% CI) 0.62(0.40-0.94), is less likely to obtain long-term treatment success. Most children and adolescents with difficult to treat AD, seemingly unresponsive to conventional treatment according to current guidelines, are able to improve with PIM. Psychosocial and family but not clinical variables, predicted long-term treatment success after participating in PIM.

Treatment of atopic dermatitis (AD) is focused on topical anti-inflammatory therapy, epidermal barrier repair and trigger avoidance. Multidisciplinary treatment in both moderate maritime and alpine climates can successfully reduce disease activity in children with AD. However, it remains unclear whether abnormalities in B cell and T cell memory normalize and whether this differs between treatment strategies. To determine whether successful treatment in maritime and alpine climates normalizes B- and T lymphocytes in children with moderate to severe AD. The study was performed in the context of a trial (DAVOS trial, registered at Current Controlled Trials ISCRTN88136485) in which eighty-eight children with moderate to severe AD were randomized to 6weeks of treatment in moderate maritime climate (outpatient setting) or in the alpine climate (inpatient setting). Before and directly after treatment, disease activity was determined with SA-EASI and serum TARC, and T cell and B cell subsets were quantified in blood. Both treatment protocols achieved a significant decrease in disease activity, which was accompanied by a reduction in circulating memory Treg, transitional B cell and plasmablast numbers. Alpine climate treatment had a significantly greater effect on disease activity and was accompanied by a reduction in blood eosinophils and increases in memory B cells, CD8+ TemRO, CD4+ Tcm and CCR7+ Th2 subsets. Clinically successful treatment of AD induces changes in blood B- and T cell subsets reflecting reduced chronic inflammation. In addition, multidisciplinary inpatient treatment in the alpine climate specifically affects memory B cells, CD8+ T cells and Th2 cells. These cell types could represent good markers for treatment efficacy.

Background. The aim of this study was to quantify behavioral problems in clinically treated children and adolescents with asthma and to examine the association of these problems and quality of life with difficult-to-treat asthma. Methods. Clinical patients with difficult-to-treat asthma (n = 31) and patients with asthma who were not classified as difficult-to-treat asthma (n = 52) completed the Pediatric Asthma Quality of Life Questionnaire [PAQLQ(S)]. Their parents completed the Child Behavior Checklist (CBCL) to assess behavioral problems. Behavioral problem scores were compared to norms of population reference groups and both behavioral problems and quality of life were compared between children and adolescents with and without difficult-to-treat asthma. Results. Especially internalizing behavioral problems such as being withdrawn/depressed and somatic complaints were more severe in the asthmatic groups compared to the healthy reference groups. The behavioral problems ‘somatic complaints’ and ‘thought problems’ as well as a lower quality of life were more severe in children and adolescents with difficult-to-treat asthma than in asthma patients who did not fulfill the criteria of difficult-to-treat asthma. Conclusions. Behavioral problems and a lower quality of life are suggested to be more pronounced in clinically treated children and adolescents with difficult-to-treat asthma than in asthma patients who are not classified as difficult-to-treat asthma. With respect to practical implications, our data suggest that health-care professionals should – especially in children and adolescents with difficult-to-treat asthma – assess and, if necessary, treat behavioral problems.

The University Medical Centre Utrecht (UMC Utrecht) has developed an eczema portal that combines e-consulting, monitoring and self-management training by a dermatology nurse online for patients and parents of young children with atopic dermatitis (AD). Patient satisfaction with the portal was high. It could be extended to become a Digital Eczema Centre for multidisciplinary collaboration between health-care providers from different locations and the patient. Before starting the construction of the Digital Eczema Centre, the feasibility was examined by carrying out a business case analysis. The purposes, strength and weaknesses showed that the Digital Eczema Centre offered opportunities to improve care for patients with AD. The financial analysis resulted in a medium/best case scenario with a positive result of euro50-240,000 over a period of five years. We expect that the Digital Eczema Centre will increase the accessibility and quality of care. The web-based patient record and the digital chain-of-care promote the involvement of patients, parents and multidisciplinary teams as well as the continuity and coordination of care.

Congestive heart failure is a major source of anxiety for both patients and their family. This article presents the results of a qualitative case study aimed at evaluating family nursing interventions from the perspective of the family members and a clinical nurse specialist (CNS). A CNS applied a family nursing intervention program with 4 couples. Data were obtained through semistructured interviews preintervention and postintervention for the couples and postintervention for the CNS. The transcripts of the interviews were submitted for content analysis. For the couples, results show both spouses subject to a high level of suffering, which can be alleviated through a family nursing meeting that allows them to obtain a better understanding of each other's experience. For the CNS, family interventions were considered a privilege since they helped relieve suffering and her own feelings of powerlessness. These results have the potential to improve family nursing interventions and enhance CNS practice.