key: cord-0252216-c2jc0a25
authors: O’Donoghue, Dara; McCaughey, Conall; Shields, Michael D
title: FACTORS ASSOCIATED WITH IMPROVED CLINICAL CONTROL IN A DIFFICULT-TO-TREAT PAEDIATRIC ASTHMA COHORT THROUGH THE COVID-19 PANDEMIC LOCKDOWN PERIOD
date: 2021-07-08
journal: Ulster Med J
DOI: nan
sha: a9b1ab68e591adf3431e5ee4fa0481b76384fc2b
doc_id: 252216
cord_uid: c2jc0a25

nan

Methimazole (active metabolite of carbimazole) has been associated with transient, asymptomatic elevations in serum aminotransferase levels, typically during the first 3 months after starting high dose, induction therapy. 1 It can also cause a clinically apparent, idiosyncratic liver injury. Onset is usually within 2 to 12 weeks of starting therapy and typically causes a cholestatic or mixed pattern of enzyme elevations, without evidence of hepatic necrosis on liver biopsy. 2 Most patients recover on drug discontinuation. There are, however, occasional reports of severe and fatal cases. The proposed mechanism of carbimazole-induced cholestasis is not fully understood. 1 This patient developed severe hyperbilirubinemia 1 year after starting treatment with carbimazole. His bilirubin level peaked at 518, significantly higher than reported levels in the literature to date. It then began to slowly settle over a period of 4 weeks. Although hepatotoxicity is a rare side effect of antithyroid medication, it can be a significant one. It is important to remember to consider it as a cause of jaundice, with the potential to occur many months after starting treatment. Patient awareness is very important and they should be counselled about the potential side effect and to consult a doctor if they notice jaundice developing. This patient waited for 6 weeks before seeking medical attention, without realising that his medication could be causing this problem.

Rebecca O' Kane 1 , Johnny Cash 2

It is recognised that fewer children attended Emergency Departments (ED) with asthma exacerbations during the COVID-19 pandemic. 1,2 However, it is unclear why. The common triggers of asthma attacks include viral infections, high pollen counts and air pollution. It would seem likely that significant changes in one of more of these would impact on asthma control. There have been no reports, to our knowledge, examining asthma control and medication adherence in a paediatric difficult to treat (DTA) asthma cohort over this period, and comparing it with air pollution and respiratory viral data. The clinical course of, and external influences upon, the Northern Irish paediatric DTA cohort through the pandemic can inform this discussion. The UK 

Hazel tree pollen (grains/m 3 ) Table 1) . Levels of airborne aeroallergens, air pollution data and prevailing respiratory viruses over the two epochs were also compared.

Unscheduled care attendance data suggested that the cohort presented significantly less to emergency services and received fewer courses of rescue OCS during the pandemic than in 2019. ACT data was better for the 2020 epoch, suggesting that these differences may be on the basis of improved asthma control. No difference in inhaler adherence was observed. This may represent a 'ceiling effect', as suboptimal adherence is improved and reinforced with remote monitoring at our DTA clinic. 4 There was no consistent pattern for tree pollen levels but there were greater levels of grass pollen in 2020. Air pollution data showed significantly lower levels of atmospheric PM 2.5 , PM 10 and SO 2 (but not NO 2 ) during the 2020 epoch.

This data suggests that shielding has been protective through the pandemic, leading to improved asthma control. The viral data may reflect the restricted movement of children, thereby limiting viral spread. Less air pollution is also likely a contributor to fewer exacerbations. Although there were greater airborne grass pollen levels in 2020, children may have been protected from outdoor exposure as a result of shielding indoors.

Once shielding stopped, children were mixing much more, resulting in greater exposure to respiratory viruses. However, schools have tried to implement measures to maintain social distancing and attenuate viral spread. It remains extremely important to optimise adherence, inhaler technique and the use of asthma plans over this period of uncertainty to help to minimise asthma morbidity. This service evaluation aimed to assess current use of PCC in Belfast Health and Social Care Trust (BHSCT), to identify areas for improvement and improve alignment between local guidance and practice on-the-ground.

Two current BHSCT guidelines on management of bleeding while receiving anticoagulants provided audit standards.

We sought records of all patients who received PCC within BHSCT between January and June 2016. We designed, piloted and adapted a pro-forma which was then used by Haemovigilance Specialist Nurses. Data were collated in Microsoft Excel and analysed using descriptive statistics to

LiverTox: clinical and research information on drug-induced liver injury. Bethesda: NIDDK; 2021

Carbimazoleinduced cholestatic hepatitis in Graves' disease

Initial effects of the COVID-19 pandemic on pediatric asthma emergency department utilization

COVID-19 lockdown dropped the rate of paediatric asthma admissions

British Pediatric Respiratory Society

Mobile direct observation of therapy (MDOT) -A rapid systematic review and pilot study in children with asthma