Severe pediatric asthma refractory to treatment : the ongoing challenge of exacerbation.

The objective of this study was to review the last 16 years of literature on the clinical and functional risk factors for asthma exacerbation, as well as on biochemical parameters in severe pediatric asthma refractory to treatment (SPART). In searches of the Cochrane/Brazilian Virtual Library of Health, Latin American and Caribbean Health Sciences Literature, Medline, Brazilian Office for the Advancement of Higher Education, and PubMed databases, we employed the following search terms/strings: ?severe asthma? or ?refractory asthma? or ?problematic asthma? or ?difficult-to-treat asthma?; ?exacerbation?; ?risk factors? or ?predictors?; and ?pediatric? or ?children and adolescents?. We limited our searches to articles published between 1999 and 2016. We selected 26 original or review articles on severe pediatric asthma that addressed age, recent severe exacerbations, the level of asthma control, regular followup, comorbidities, behavioral factors, viral infection, and passive smoking, biomarkers of inflammation, serum vitamin D levels, and pulmonary function. However, we found very few studies dealing with SPART. Severe asthma is a heterogeneous, dynamic disease in which the various predictors of exacerbation described assess different aspects of the disease and are complementary. Such factors should be analyzed from a multifactorial and individualized perspective, because many of them are potentially modifiable

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear un derstanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5–7 vast areas of the tropics remain understudied.8–11 In the American tropics, Amazonia stands out as the world’s most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepre sented in biodiversity databases.13–15 To worsen this situation, human-induced modifications16,17 may elim inate pieces of the Amazon’s biodiversity puzzle before we can use them to understand how ecological com munities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple or ganism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region’s vulnerability to environmental change. 15%–18% of the most ne glected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lostinfo:eu-repo/semantics/publishedVersio

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear understanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5,6,7 vast areas of the tropics remain understudied.8,9,10,11 In the American tropics, Amazonia stands out as the world's most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepresented in biodiversity databases.13,14,15 To worsen this situation, human-induced modifications16,17 may eliminate pieces of the Amazon's biodiversity puzzle before we can use them to understand how ecological communities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple organism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region's vulnerability to environmental change. 15%–18% of the most neglected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lost

Question 2:What are the effects of inhaled corticosteroids on growth in children?

This review summarizes the current evidence regarding the effects of inhaled corticosteroids (ICS) on growth in children with asthma. The evidence from randomized trials showed a mean reduction of -0.48 cm/year (95% CI -0.65 to -0.30) in linear growth velocity and of -0.61 cm (95% CI -0.83 to -0.38) in height during a one-year treatment with ICS. Some first-generation drugs had a slightly larger suppressive effect on growth than newer drugs, with a mean reduction in linear growth velocity of -0.91, -0.59, -0.08 and -0.39 cm/year for beclomethasone, budesonide, ciclesonide and fluticasone, respectively. There was evidence of a dose-response relationship, with medium doses (HFA-beclomethasone or equivalent, 100-200 mu g/day) producing a greater reduction than low doses (50-100 mu g/day), in height, but not in linear growth velocity. ICS-induced growth suppression was less pronounced during subsequent years of treatment. Most "real life" observational studies did not show significant suppressive effects of ICS on long-term growth or adult height, and some studies found an initial growth reduction related to ICS which did not persist in subsequent years. It remains unclear to what extent long-term ICS use in childhood has an effect on final adult height. It appears that the deleterious effects of ICS on adult height, if any, are small (max 1.2 cm). In conclusion, use of ICS in prepubertal children with asthma is associated with a small but dose dependent depression in growth in the first year of treatment, but no clinically relevant effect on adult height. (C) 2018 Elsevier Ltd. All rights reserved