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Ramesh J Kurukulaaratchy,1–4 Hitasha Rupani,1 Wei Chern Gavin Fong,2,3 Aref Kyyaly2,3 1Department of Respiratory Medicine, University Hospitals Southampton NHS Foundation Trust, Southampton, UK; 2Clinical and Experimental Sciences, University of Southampton, Southampton, UK; 3David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight, UK; 4NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UKCorrespondence: Ramesh J KurukulaaratchyWei Chern Gavin Fong Clinical and Experimental Sciences, University of Southampton, Southampton, UKTel +44 238120 5232Email R.J.Kurukulaaratchy@soton.ac.uk; W.C.Fong@soton.ac.uk View the original paper by Dr Rupani and colleagues This is in response to the Letter to the Editor

BackgroundPatients with malignant pleural mesothelioma (MPM) have a life-limiting illness and short prognosis and experience many debilitating symptoms from early in the illness. Innovations such as remote symptom monitoring are needed to enable patients to maintain wellbeing and manage symptoms in a proactive and timely manner. The Advanced Symptom Management System (ASyMS) has been successfully used to monitor symptoms associated with cancer. ObjectiveThis study aimed to determine the feasibility and acceptability of using an ASyMS adapted for use by patients with MPM, called ASyMSmeso, enabling the remote monitoring of symptoms using a smartphone. MethodsThis was a convergent mixed methods study using patient-reported outcome measures (PROMs) at key time points over a period of 2-3 months with 18 patients. The Sheffield Profile for Assessment and Referral for Care (SPARC), Technology Acceptance Model (TAM) measure for eHealth, and Lung Cancer Symptom Scale-Mesothelioma (LCSS-Meso) were the PROMs used in the study. Patients were also asked to complete a daily symptom questionnaire on a smartphone throughout the study. At the end of the study, semistructured interviews with 11 health professionals, 8 patients, and 3 carers were conducted to collect their experience with using ASyMSmeso. ResultsEighteen patients with MPM agreed to participate in the study (33.3% response rate). The completion rates of study PROMs were high (97.2%-100%), and completion rates of the daily symptom questionnaire were also high, at 88.5%. There were no significant changes in quality of life, as measured by LCSS-Meso. There were statistically significant improvements in the SPARC psychological need domain (P=.049) and in the “Usefulness” domain of the TAM (P=.022). End-of-study interviews identified that both patients and clinicians found the system quick and easy to use. For patients, in particular, the system provided reassurance about symptom experience and the feeling of being listened to. The clinicians largely viewed the system as feasible and acceptable, and areas that were mentioned included the early management of symptoms and connectivity between patients and clinicians, leading to enhanced communication. ConclusionsThis study demonstrates that remote monitoring and management of symptoms of people with MPM using a mobile phone are feasible and acceptable. The evidence supports future trials using remote symptom monitoring to support patients with MPM at home.

Background: The COP28 Declaration on Climate and Health promotes steps to curb emissions and reduce waste in the health sector., Objective: To describe and quantify greenhouse gas (GHG) emissions associated with severe asthma (SA) care in the UK, by carbon source and transition status from SA to severe uncontrolled asthma (SUA) and/or regular specialist care (RSC)., Methods: This was a cohort study using routinely collected data from the Clinical Practice Research Datalink Aurum, Hospital Episode Statistics and CO 2 equivalent emissions data. Patients were ≥12 years old at index date (i.e. date of first recorded ICS + controller prescription) with a validated asthma diagnosis. Total-, medication-, exacerbation- and healthcare resource utilisation (HCRU)-related GHG emissions were estimated, overall and by transition along stages of the SA-SUA-RSC continuum. Five pathways and stage orders were identified: 1. SA, 2. SA-SUA, 3. SA-RSC, 4. SA-RSC-SUA, 5. SA-SUA-RSC., Results: Total CO 2 eq for the SA population (n=93,054) was 2167 tonnes/10K patients/year. GHG emissions were 5.2-23.0% greater for patients transitioned to SUA (versus previous stage), mostly due to exacerbation-related emissions (4.2-7.7 times greater; predominantly hospitalizations) and medication-related emissions (3.5-10.9% greater; predominantly SABAs). Conversely, total GHG emissions decreased by 12.1-23.9% for those referred to RSC, due to decreased exacerbation-related emissions (1.7-5.2 times lower; all sources) and medication-related emissions (14.8-20.6% lower; both SABA and overall ICS)., Conclusion: Our findings suggest that RSC not only improves patient outcomes but also reduces GHG emissions in line with aims to reduce the health sector's contribution to the total national carbon footprint., (Copyright © 2025. Published by Elsevier Inc.)

Uncontrolled asthma is associated with an increased risk of adverse perinatal outcomes. Asthma biologics reduce exacerbation frequency, are steroid sparing, and improve quality of life in people with severe asthma. However, evidence for the use and safety of asthma biologics during pregnancy is scarce, largely because pregnant women were excluded from clinical trials. To help to support clinical teams, we conducted an international modified Delphi study. 141 panellists from 32 countries who were involved in the care of people with severe asthma completed two rounds of online surveys covering key areas surrounding the use of asthma biologics in pregnancy. The results from this international Delphi study emphasise risk versus benefit discussions and shared clinical decision making, with consensus among panellists that asthma biologics can be used during conception and throughout pregnancy, initiated during pregnancy in line with prescribing criteria for non-pregnant people, and initiated or continued during breastfeeding. Collating data through international registries remains essential to inform clinical guidelines., Competing Interests: Declaration of interests JN and MC declare no competing interests. DJJ has received advisory board and speaker fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GSK, Novartis, and Sanofi and research grant funding to his institution from AstraZeneca. GdA has received grants from AstraZeneca, GSK, and Chiesi; consulting fees and payment for educational events from AstraZeneca, GSK, Sanofi, and Chiesi; and support to attend meetings from Chiesi and Sanofi. LGH has received research grant funding to his institution from GSK, AstraZeneca, and Roche/Genentech; lectures fees from AstraZeneca, Novartis, Roche, Genentech, Sanofi, Circassia, GSK, Chiesi, and Teva; and travel funding from AstraZeneca and GSK. LGH has sat on Novartis, Roche/Genentech, GSK, Teva, and Celltrion monitoring and advisory boards. PD has received advisory board fees, speaker fees, and congress travel support from AstraZeneca, GSK, Chiesi, and Sanofi. AB has received research grant funding to his institution from AstraZeneca and lecture fees from Chiesi. HR has received advisory board and speaker fees from GSK, Chiesi, AstraZeneca, Sanofi, and Boehringer Ingelheim; conference support from AstraZeneca; and grant funding to her institution from AstraZeneca and GSK., (Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Protocol-guided multidisciplinary team supported steroid weaning is effective in reducing maintenance OCS use in most biologic-naïve patients with severe asthma, supporting the concept that maintenance OCS are inappropriate treatments for severe asthma https://bit.ly/4cgrJEL., Competing Interests: Conflicts of interest: C. Whitfield has received speaker fees from AstraZeneca. P. Dennison has received advisory board, speaker fees and congress travel support from AstraZeneca, GSK, Chiesi and Sanofi. H. Rupani has received advisory board and speaker fees from GSK, Chiesi, AstraZeneca, Sanofi and Boehringer Ingelheim; conference support from AZ and Sanofi; and grant funding to her institution from AZ and GSK; and is an associate editor of this journal. E.R. Graham, C. Eames, W. Soe, L. Fox, S. Kerley, M. Pantaleon, J. McCreery, P. Cook, A. Freeman, H.M. Haitchi, R.J. Kurukulaaratchy, A. Day, J.J. Hudson-Colby and N. Zarif have no conflict of interest., (Copyright ©The authors 2024.)

Background: We have previously developed Core Outcome Measures sets for Severe Asthma (COMSA) by multi-stakeholder consensus. There are no patient-centred tools to quantify response to biologics for severe asthma. We aimed to develop paediatric and adult CompOsite iNdexes For Response in asthMa (CONFiRM) incorporating clinical parameters and patient-reported quality of life (QoL)., Methods: International expert healthcare professionals (HCPs) and patients with severe asthma were invited to: 1) develop consensus levels of clinically relevant changes for each outcome measure within COMSA; 2) use multicriteria decision analysis to develop the CONFiRM scores and 3) assess their internal validity. A separate group of HCPs evaluated CONFiRM's external validity., Results: Five levels of change for each COMSA outcome were agreed. Severe exacerbations and maintenance oral corticosteroids use were rated as most important in determining both paediatric and adult CONFiRM scores. There was strong agreement between HCPs and patients, although patients assigned greater importance to QoL. The CONFiRM score quantified response to a biological from -31 (deterioration) to 69 (best possible response). Paediatric and adult CONFiRMs had good discriminative ability for a sufficient (AUC≥0.92) and a substantial (AUC≥0.95) response to biologics. Both CONFiRMs demonstrated excellent external validity (Spearman correlation coefficients 0.9 and 0.8 for paediatric and adult respectively (p<0.0001))., Conclusions: We have developed novel patient-centred paediatric and adult CONFiRMs which include QoL measures. CONFiRMs should allow a more holistic understanding of response for the patient and a standardised assessment of the effectiveness of biologics between studies. Further research is needed to prospectively validate CONFiRM scores., (Copyright ©The authors 2024.)

Background: Type 2 low-severe asthma phenotype is often a result of corticosteroid-overtreated type 2 disease owing to persistent symptoms, often unrelated to asthma and unlikely to respond to high-dose corticosteroid treatment., Objective: This study aimed to characterize patients with severe asthma with low eosinophil counts (<300 cells/μL) and describe their disease burden and treatment across health care settings in the United Kingdom., Methods: A retrospective cohort study of patients with severe asthma using linked Clinical Practice Research Datalink (CPRD) Aurum-Hospital Episode Statistics (HES) and UK Severe Asthma Registry (UKSAR) data indexed patients according to the latest blood eosinophil count (BEC). Clinical characteristics, treatment patterns, outcomes, and health care resource use were described by baseline BEC (≤150 and >150 to <300 cells/μL)., Results: Analysis included 701 (CPRD-HES) and 1,546 (UKSAR) patients; 60.5% and 59.4% had BECs 150 cells/μL or less at baseline, respectively. Across BEC groups, the proportion with uncontrolled asthma (two or more exacerbations) at follow-up (12 months after the index) was 5.4% in CPRD-HES and 45.2% in UKSAR. Maintenance oral corticosteroid use remained high across BEC groups (CPRD-HES: 29.4%; UKSAR: 51.7%), symptom control remained poor (>200 μg short-acting β 2 agonist or >500 μg terbutaline/d in CPRD-HES: 48.8%; median Asthma Control Questionnaire-6 score in UKSAR: 2.0 [range, 1.0-3.3]). Health care resource use was similar across BEC groups., Conclusions: Most patients managed in primary care experienced infrequent exacerbations, whereas UKSAR patients had frequent exacerbations. Large proportions of both patient groups had poor symptom control and continued to receive high levels of maintenance oral corticosteroids, increasing the risk of corticosteroid-induced morbidity. These data highlight the need for rigorous assessment of underlying disease pathology to guide appropriate treatment., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)