Onset and remission of allergic rhinitis and asthma and the relationship with atopic sensitization and smoking

Nasal endoscopic findings and nasal symptoms in patients with asthma: a clinical study from a rhinological perspective

OBJECTIVE

Allergic rhinitis (AR), non-allergic rhinitis (NAR), chronic rhinosinusitis with nasal polyps (CRSwNP), and chronic rhinosinusitis without nasal polyps (CRSsNP) occur frequently in asthmatic patients. We evaluated nasal symptoms and nasal endoscopic findings in patients with asthma and correlated them to asthma severity.

METHODS

Subjects (n=150) with asthma completed questionnaires designed to provide information related to asthma and nasal disease. Patients were divided into four groups based on asthma severity. Pulmonary function tests, skin-prick tests (SPTs) and nasal endoscopy were performed on every patient. Clinical findings were compared in asthma patients by rhinologists.

RESULTS

The total incidence of AR, NAR, CRSwNP and CRSsNP in these patients with asthma was 76%. By using Fisher's Exact Test, there was no statistical significance between asthma severity and the incidence of AR, NAR, CRSwNP and CRSsNP (P=0.311). There was a significant difference in the total nasal symptoms score among subjects with different grades of asthma (P=0.002). However, there were no significant differences in the total Lund-Kennedy endoscopic score (LKS) (P=0.736). The nasal endoscopic scores were significantly correlated at a high degree with the nasal symptoms score (P=0.000). A significant correlation was found between the nasal endoscopic score and the duration of asthma in the patients with different grades of asthma (P<0.05).

CONCLUSIONS

The relationship between rhinitis and asthma is complex. Nasal airways should become part of standard clinical assessment and follow-up in patients with asthma.

[Influence of tobacco smoking on the risk of developing asthma]

The aim of this general review is to investigate the influence of active and passive smoking on the development of asthma in children and adults. Passive smoking during and after pregnancy facilitates the onset of childhood asthma and wheezing. In particular, smoking during pregnancy is associated with the occurrence of wheezing prior to the age of 4 years. In contrast, the results of studies on the relationship between parental smoking in the post-natal period and the onset of asthma or wheezing are discordant. Exposure to passive smoking during childhood facilitates the occurrence of asthma in adulthood. In adults and adolescents, active smoking appears to be a factor favoring the development of asthma. On the other hand, non-smoking adult subjects without history of asthma exposed to passive smoking have a risk of asthma. The pathophysiological mechanisms by which tobacco smoke is the cause of asthma are still poorly known. Smoking cessation is an essential component in the management of asthmatic subjects who smoke, facilitating the control of the disease.

Developing and emerging clinical asthma phenotypes

For more than a century, clinicians have attempted to subdivide asthma into different phenotypes based on triggers that cause asthma attacks, the course of the disease, or the prognosis. The first phenotypes that were described included allergic asthma, intrinsic or nonallergic asthma, infectious asthma, and aspirin-exacerbated asthma. These phenotypes are being reviewed elsewhere in this issue of the journal. The present article focuses on developing and emerging clinical asthma phenotypes. First, asthma phenotypes that are associated with environmental exposures (occupational agents, cigarette smoke, air pollution, cold dry air); second, asthma phenotypes that are associated with specific symptoms or clinical characteristics (cough, obesity, adult onset of disease); and third, asthma phenotypes that are based on biomarkers. This latter approach is the most promising because it attempts to identify asthma phenotypes with different underlying mechanisms so that therapies can be better targeted toward disease-specific features and disease outcomes can be improved.

Mode of dendritic cell activation: the decisive hand in Th2/Th17 cell differentiation. Implications in asthma severity?

Asthma is a heterogeneous chronic inflammatory disease of the airways, with reversible airflow limitations and airway remodeling. The classification of asthma phenotypes was initially based on different combinations of clinical symptoms, but they are now unfolding to link biology to phenotype. As such, patients can suffer from a predominant eosinophilic, neutrophilic or even mixed eosinophilic/neutrophilic inflammatory response. In adult asthma patients, eosinophilic inflammation is usually seen in mild-to-moderate disease and neutrophilic inflammation in more severe disease. The underlying T cell response is predominated by T helper (Th) 2, Th17, or a mixed Th2/Th17 cell immune response. Dendritic cells (DCs) are "professional" antigen presenting cells (APCs), since their principal function is to present antigens and induce a primary immune response in resting naive T cells. DCs also drive the differentiation into distinctive Th subsets. The expression of co-stimulatory molecules and cytokines by DCs and surrounding cells determines the outcome of Th cell differentiation. The nature of DC activation will determine the expression of specific co-stimulatory molecules and cytokines, specifically needed for induction of the different Th cell programs. Thus DC activation is crucial for the subsequent effector Th immune responses. In this review, we will discuss underlying mechanisms that initiate DC activation in favor of Th2 differentiation versus Th1/Th17 and Th17 differentiation in the development of mild versus moderate to severe asthma.

Efficacy of nasal mometasone for the treatment of chronic sinonasal disease in patients with inadequately controlled asthma

BACKGROUND

Chronic sinonasal disease is common in asthmatic patients and associated with poor asthma control; however, there are no long-term trials addressing whether chronic treatment of sinonasal disease improves asthma control.

OBJECTIVE

We sought to determine whether treatment of chronic sinonasal disease with nasal corticosteroids improves asthma control, as measured by the Childhood Asthma Control Test and Asthma Control Test in children and adults, respectively.

METHODS

A 24-week multicenter, randomized, placebo-controlled, double-blind trial of placebo versus nasal mometasone in adults and children with inadequately controlled asthma was performed. Treatments were randomly assigned, with concealment of allocation.

RESULTS

Two hundred thirty-seven adults and 151 children were randomized to nasal mometasone versus placebo, and 319 participants completed the study. There was no difference in the Childhood Asthma Control Test score (difference in change with mometasone - change with placebo [ΔM - ΔP], -0.38; 95% CI, -2.19 to 1.44; P = .68; age 6-11 years) or the Asthma Control Test score (ΔM - ΔP, 0.51; 95% CI, -0.46 to 1.48; P = .30; age ≥12 years) in those assigned to mometasone versus placebo. In children and adolescents (age 6-17 years) there was no difference in asthma or sinus symptoms but a decrease in episodes of poorly controlled asthma defined by a decrease in peak flow. In adults there was a small difference in asthma symptoms measured by using the Asthma Symptom Utility Index (ΔM - ΔP, 0.06; 95% CI, 0.01 to 0.11; P < .01) and in nasal symptoms (sinus symptom score ΔM - ΔP, -3.82; 95% CI, -7.19 to -0.45; P = .03) but no difference in asthma quality of life, lung function, or episodes of poorly controlled asthma in adults assigned to mometasone versus placebo.

CONCLUSIONS

Treatment of chronic sinonasal disease with nasal corticosteroids for 24 weeks does not improve asthma control. Treatment of sinonasal disease in asthmatic patients should be determined by the need to treat sinonasal disease rather than to improve asthma control.

Multiple chronic conditions and asthma: implications for practice and research

At least half of US adults with asthma have at least 1 other chronic condition. Having asthma and other chronic conditions are associated with poorer asthma outcomes. Several studies considered the relationship between asthma and other specific chronic conditions; results of these studies indicated that having depression or anxiety and/or panic disorder is associated with an increased risk of developing a new asthma diagnosis and with poorer asthma outcomes. In addition, results of these studies indicated that having asthma is associated with an increased risk of developing a new depression or anxiety and/or panic disorder diagnosis. Theoretical models for understanding multiple chronic conditions have emerged, with models that include a balance between patient workload and capacity; classification of specific conditions as concordant and/or discordant and/or dominant; and identification of the gap between what a patient needs and what health care services are able to offer. Potential implications for clinical providers include screening for chronic conditions not yet recognized, such as mental health disorders, promoting and tracking medication adherence in those who have multiple chronic conditions, and simplifying treatment regimens to reduce patient workload.

Age at onset of asthma and allergen sensitization early in life

BACKGROUND

Epidemiological evidence indicates that the age at onset of asthma and allergen sensitization in early life is decreasing in people from Western countries. To explore latent trends, we conducted a retrospective examination of the age at onset of asthma and specific IgE antibodies against inhalant allergens in Japanese asthmatic children.

METHODS

We conducted a case series study of 103 consecutive children with atopic type of asthma (aged 2 years to 16 years, mean age 9.4 ± 3.4 years). Diagnoses of asthma and allergic rhinitis were defined according to Japanese guidelines. The onset of asthma and allergic rhinitis was also defined as any report of asthma and allergic rhinitis confirmed by a physician. Allergen sensitization was evaluated as specific serum IgE levels for 9 common inhalant allergens in peripheral blood. Atopic type of asthma was defined as a being positive for at least one aeroallergen.

RESULTS

Mean age at asthma onset was 2.3 ± 1.9 years, which is slightly lower than that of previous reports, including those published in Japan. A high prevalence rate of up to 80% was found for perennial antigens including Dermatophagoides spp. and house dust, as reported previously. Notably, some of the children aged at 1 year tested positive for these allergens.

CONCLUSIONS

The age at onset of asthma seems to be decreasing in comparison with previous reports. Furthermore, the age at onset of allergen sensitization against inhalant allergens appears to follow this trend.

Active or passive exposure to tobacco smoking and allergic rhinitis, allergic dermatitis, and food allergy in adults and children: a systematic review and meta-analysis

BACKGROUND

Allergic rhinitis, allergic dermatitis, and food allergy are extremely common diseases, especially among children, and are frequently associated to each other and to asthma. Smoking is a potential risk factor for these conditions, but so far, results from individual studies have been conflicting. The objective of this study was to examine the evidence for an association between active smoking (AS) or passive exposure to secondhand smoke and allergic conditions.

METHODS AND FINDINGS

We retrieved studies published in any language up to June 30th, 2013 by systematically searching Medline, Embase, the five regional bibliographic databases of the World Health Organization, and ISI-Proceedings databases, by manually examining the references of the original articles and reviews retrieved, and by establishing personal contact with clinical researchers. We included cohort, case-control, and cross-sectional studies reporting odds ratio (OR) or relative risk (RR) estimates and confidence intervals of smoking and allergic conditions, first among the general population and then among children. We retrieved 97 studies on allergic rhinitis, 91 on allergic dermatitis, and eight on food allergy published in 139 different articles. When all studies were analyzed together (showing random effects model results and pooled ORs expressed as RR), allergic rhinitis was not associated with active smoking (pooled RR, 1.02 [95% CI 0.92-1.15]), but was associated with passive smoking (pooled RR 1.10 [95% CI 1.06-1.15]). Allergic dermatitis was associated with both active (pooled RR, 1.21 [95% CI 1.14-1.29]) and passive smoking (pooled RR, 1.07 [95% CI 1.03-1.12]). In children and adolescent, allergic rhinitis was associated with active (pooled RR, 1.40 (95% CI 1.24-1.59) and passive smoking (pooled RR, 1.09 [95% CI 1.04-1.14]). Allergic dermatitis was associated with active (pooled RR, 1.36 [95% CI 1.17-1.46]) and passive smoking (pooled RR, 1.06 [95% CI 1.01-1.11]). Food allergy was associated with SHS (1.43 [1.12-1.83]) when cohort studies only were examined, but not when all studies were combined. The findings are limited by the potential for confounding and bias given that most of the individual studies used a cross-sectional design. Furthermore, the studies showed a high degree of heterogeneity and the exposure and outcome measures were assessed by self-report, which may increase the potential for misclassification.

CONCLUSIONS

We observed very modest associations between smoking and some allergic diseases among adults. Among children and adolescents, both active and passive exposure to SHS were associated with a modest increased risk for allergic diseases, and passive smoking was associated with an increased risk for food allergy. Additional studies with detailed measurement of exposure and better case definition are needed to further explore the role of smoking in allergic diseases.

Sinusitis, Rhinitis, Asthma, and the Single Airway Hypothesis

The one airway, one disease hypothesis proposes that the upper and lower airways share the same physiology and histomorphology. Epidemiological clinical studies support a link between rhinosinusitis and asthma. The relationship can occur in both directions, with nasal allergen challenge leading to inflammatory changes in the lower airway and bronchoprovocation studies of the lower airway leading to inflammatory changes in the upper airway. In addition, both similarities and differences exist in the pathogenesis of nasal polyps and asthma. The mechanism for the connection between the upper and lower airways is a matter of great debate. It has been proposed that inflammatory changes in the lower airway may lead to systemic inflammatory effects that play a role in increased bronchial hyperresponsiveness. Similarly, lower airway inflammatory changes may affect nasal airway patency via systemic effects. Moreover, nasopharyngeal-bronchial reflexes may play a non-immunologic role in the interaction between the lower and upper airways. An example of the connection between the upper and lower airways is found in aspirin-exacerbated respiratory disease whereby leukotrienes play a role in the pathology of chronic rhinosinusitis with polyps and asthma. It is also been observed that the treatment of asthma is hindered by untreated rhinosinusitis.

Chronic rhinitis and its association with headache frequency and disability in persons with migraine: Results of the American Migraine Prevalence and Prevention (AMPP) Study

Background

Rhinitis is a comorbidity of migraine, but its relationship to migraine headache frequency and headache-related disability is unknown.

Objectives

To determine if rhinitis and its subtypes are associated with an increased frequency and associated disability of migraine.

Methods

The AMPP Study is a longitudinal study of individuals with “severe” headache from the US population. Respondents meeting ICHD-2 criteria for migraine in 2008 were identified and the presence of rhinitis was determined using the European Community Respiratory Health Survey (ECRHS). Those with rhinitis were subtyped as allergic, non-allergic, mixed and unclassified based on a rhinitis questionnaire. The primary outcome measures were categories of headache-day frequency and headache-related disability as measured by the Migraine Disability Assessment Scale (MIDAS). Logistic regression for ordered categories was used for modeling each outcome separately, adjusted for sociodemographics profile, headache features, headache treatments and comorbidities.

Results

The AMPP Study questionnaire was mailed to 17,892 persons and returned by 60.1% of respondents. Among the migraine sample ( n = 5849), 66.8% had rhinitis with mixed rhinitis as the most common form. The presence of rhinitis of any type was associated with headache frequency after adjusting for sociodemographic variables only (OR 1.33; 95% CI 1.16, 1.53) and in the fully adjusted model (OR 1.25; 95% CI 1.05–1.49). Headache-related disability (MIDAS category) was associated with rhinitis after adjusting for sociodemographic features (OR 1.30; 95% CI 1.17–1.46), but lost significance in the fully adjusted model (OR 1.10; 95% CI 0.96–1.26). Mixed rhinitis was associated with an increased headache frequency category in the model adjusted for sociodemographics (OR 1.45; 95% CI 1.24–1.70) and in that adjusted for all covariates (OR 1.28; 95% CI 1.05–1.57). The odds ratio for MIDAS categories were similarly increased in both models for the mixed rhinitis group.

Conclusions

The frequency and disability of migraine are higher in persons with rhinitis, particularly those with mixed rhinitis. These results, however, should be considered preliminary until confirmed in future studies because of the modest questionnaire response rate in this study.

Allergies and risk of pancreatic cancer: a pooled analysis from the Pancreatic Cancer Case-Control Consortium

In order to quantify the risk of pancreatic cancer associated with history of any allergy and specific allergies, to investigate differences in the association with risk according to age, gender, smoking status, or body mass index, and to study the influence of age at onset, we pooled data from 10 case-control studies. In total, there were 3,567 cases and 9,145 controls. Study-specific odds ratios and 95% confidence intervals were calculated by using unconditional logistic regression adjusted for age, gender, smoking status, and body mass index. Between-study heterogeneity was assessed by using the Cochran Q statistic. Study-specific odds ratios were pooled by using a random-effects model. The odds ratio for any allergy was 0.79 (95% confidence interval (CI): 0.62, 1.00) with heterogeneity among studies (P < 0.001). Heterogeneity was attributable to one study; with that study excluded, the pooled odds ratio was 0.73 (95% CI: 0.64, 0.84) (Pheterogeneity = 0.23). Hay fever (odds ratio = 0.74, 95% CI: 0.56, 0.96) and allergy to animals (odds ratio = 0.62, 95% CI: 0.41, 0.94) were related to lower risk, while there was no statistically significant association with other allergies or asthma. There were no major differences among subgroups defined by age, gender, smoking status, or body mass index. Older age at onset of allergies was slightly more protective than earlier age.

Influences of smoking and aging on allergic airway inflammation in asthma

Asthma is a heterogeneous disease with varying phenotypes and numerous risk factors. This condition results from complex interactions between genetic and environmental factors, and active smoking is one of these risk factors. The effects of aging should also be taken into account in these interactions. From an epidemiological standpoint, smokers and/or elderly patients with asthma are not small part in the total population with asthma. Furthermore, both smoking and aging are important risk factors for severe asthma. This review discusses the potential effects of smoking and aging on healthy subjects and patients with asthma, particularly from the perspective of inflammatory changes. First we show evidence that smokers and the elderly have increased neutrophil counts in their airways, which may have impacts on their clinical characteristics of elderly smokers with asthma. Secondly, on the basis of our recent findings on the interactions between smoking and aging in patients with asthma, we propose that IgE/eosinophilic inflammation should not be underestimated in elderly smokers with asthma, particularly those who are atopic. This review may expand our understanding of the effects of smoking and aging on asthma with a new perspective of an old issue.

Obesity and asthma: a coincidence or a causal relationship? A systematic review

BACKGROUND AND AIM

Epidemiological data has established increasing adiposity as a risk factor for incident asthma. However, the mechanisms underlying the association between obesity and asthma are incompletely understood. In the present paper, we review current knowledge of possible mechanisms mediating the observed association between obesity and asthma.

METHODS

Systematic literature review.

RESULTS

Obesity and asthma share some etiological factors, such as a common genetic predisposition and effects of in utero conditions, and may also have common predisposing factors such as physical activity and diet. Obesity results in important changes in the mechanical properties of the respiratory system which could explain the occurrence of asthma. However, there are also plausible biological mechanisms whereby obesity could be expected to either cause or worsen asthma. These include co-morbidities such as gastro-oesophageal reflux, complications from sleep-disordered breathing, breathing at low lung volumes, chronic systemic inflammation, and endocrine factors, including adipokines and reproductive hormones. Obesity related asthma is in general not associated with eosinophilic airway inflammation, and adipokines are likely to play important roles in the inflammatory pathogenesis of asthma in obese individuals.

CONCLUSION

The association between obesity and asthma is not straightforward, and further knowledge is clearly needed, as understanding the underlying mechanisms may lead to new therapeutic options for this high-risk part of the asthma population.

Sensitization to pets is a major determinant of persistent asthma and new asthma onset in Sweden

INTRODUCTION

Our knowledge about atopy as a longitudinal predictor of asthma is limited. The purpose of this study was to investigate the prognosis of asthma and risk factors for asthma onset, especially sensitization of specific allergens in a population sample.

MATERIAL AND METHODS

A cohort responded to a respiratory questionnaire in 1990 and 2003. At baseline, 2,060 subjects who, in the screening questionnaire, reported respiratory symptoms and 482 controls were investigated with interviews, spirometry, and skin-prick test. A total of 721 asthmatics and 976 subjects without respiratory disease were clinically verified. At follow-up in 2003, 340 subjects with persistent asthma and 186 subjects with asthma remission were identified, while 76 subjects reported new asthma onset.

RESULTS

Sensitization to pets and a high symptom score were significant determinants of persistent asthma (odds ratio (OR) 3.2 (95% CI 1.9-5.6) and 5.7 (2.5-13.3), respectively) and onset of asthma (OR 2.6 (1.1-6.0), and 1.7 (1.2-2.3)). A high self-reported responsiveness to airway irritants (OR 1.6 (1.1-2.2)), and more asthma medications (OR 2.0 (1.3-2.9)) were additional indicators of persistent asthma at the follow-up. Belonging to the older age group decreased the risk both of having persistent asthma and asthma onset.

DISCUSSION

Asthmatics sensitized to pets have a more severe outcome than asthmatics not sensitized to pets. Sensitization to pets was also a strong predictor for onset of asthma. Special attention should be given to asthmatics who report having severe symptoms and problems with airway irritants as such patients are more likely to have persistent problems.

The role of smoking in allergy and asthma: lessons from the ECRHS

The European Community Respiratory Health Survey is an international multicenter cohort study of asthma, allergy, and lung function that began in the early-1990s with recruitment of population-based samples of 20- to 44-year-old adults, mainly in Europe. The aims of the study are broad ranging but include assessment of the role of in utero exposure to tobacco smoke, exposure to environmental tobacco smoke, and active smoking on the incidence, prevalence, and prognosis of allergy and asthma. Cross-sectional and longitudinal analyses looking at these associations have been conducted, sometimes only using information collected in one country, and on other occasions using information collected in all the participating centers. This article summarizes the results from these various publications from this large epidemiologic study.

Exhaled nitric oxide may predict bronchial hyperreactivity in patients with allergic rhinitis

BACKGROUND

Nowadays it is possible to assess airway inflammation by measuring the fractional concentration of exhaled nitric oxide (FeNO) during an office visit and there is international consensus on the testing methodology. The aim of this study was to evaluate whether FeNO measurement may be a predictor of bronchial hyperreactivity (BHR) in patients with allergic rhinitis (AR).

METHODS

Two hundred eleven patients (196 males, median age 28.5 years) suffering from persistent AR were evaluated. Values for bronchial function (FVC, FEV(1), and FEF(25-75)), bronchial provocation tests (methacholine), exhaled nitric oxide (FeNO), a visual analogue scale for nasal and bronchial symptoms, and sensitization were assessed.

RESULTS

A strong and inverse correlation between FeNO levels and BHR severity was found (r = -0.58). FeNO was a predictive factor for BHR, and 37 ppb was found to be the best cutoff (area under the curve 0.90) to define the presence of BHR in patients with AR.

CONCLUSIONS

This study highlights the relevance of FeNO as a possible predictive marker for BHR in AR patients and underlines the close link between upper and lower airways. Thus, FeNO measurement could be a useful screening tool in identifying subjects with rhinitis at risk of developing asthma.

Relationship between posttraumatic stress disorder and asthma among New York area residents exposed to the World Trade Center disaster

OBJECTIVE

The heightened prevalence rates of respiratory problems and posttraumatic stress disorder (PTSD) among New York area residents following the World Trade Center disaster on September 11, 2001, have received national attention. Although there is some evidence suggesting that PTSD is associated with increased risk for asthma, this relationship has not been well documented in this population at high risk for both disorders. There is also a need to examine this relationship while controlling for notable confounds, including dust exposure and smoking.

METHOD

This study examined the association between symptoms indicative of probable PTSD and the diagnosis of asthma following 9/11 among the individuals who participated in the World Trade Center Health Registry (WTCHR) baseline study between September 2003 and November 2004. A total of 71,437 participants enrolled in this study and completed questionnaires pertaining to exposure, physical health symptoms before and after 9/11, and self-reported PTSD symptoms.

RESULTS

Logistic regression revealed that, compared to participants without probable PTSD, individuals with probable PTSD were 1.65 times more likely to be diagnosed with asthma following 9/11, which was significant after controlling for the effects of gender, ethnicity, income, smoking status, dust exposure, and nonspecific psychological distress [Wald χ(2) (1)=52.375, P<.001].

CONCLUSION

These results suggest that PTSD symptoms are associated with the development of asthma following 9/11 and that this relationship is not explained by sociodemographic, environmental, and lifestyle factors.

Early impact of smoking on lung function, health, and well-being in adolescents

BACKGROUND

Smoking is the single most important risk factor for the development of chronic obstructive pulmonary disease, and more than 80% of adult smokers started smoking before the age of 20. The aim of our study was to evaluate the early impact of smoking on lung function, health, and well-being in adolescents.

METHODS

Twenty-four non-smokers (10 male, 14 female, mean age 17.6 years) and 24 smokers (mean of 3.5 pack-years; 15 male, 9 female, mean age 17.8 years) were compared in terms of lung function, bronchial hyperreactivity (BHR), levels of exhaled carbon monoxide (eCO), exhaled nitric oxide (eNO), and blood counts. A questionnaire containing items from the ISAAC study was used to detect differences in health and well-being.

RESULTS

There were no significant differences in lung function values between non-smokers and smokers (VC 95% vs. 103%, FEV(1) 106% vs. 116%, FEV(1) %/VC MAX 94.6% vs. 95.2%), whereas BHR significantly differed (P < 0.05). Furthermore, significant differences were found for eCO, eNO, Hb, leukocytes, and neutrophils. Health and well-being in terms of sleep and physical activity were significantly worse in smokers.

CONCLUSION

Our results suggest an early impact of smoking on health after as few as 3.5 pack-years. Early signs of smoking are an increase in BHR, changes in blood count and a decrease of eNO even before changes in lung function become apparent.

Poor asthma control?--then look up the nose. The importance of co-morbid rhinitis in patients with asthma

Many factors can impair asthma control. One which is frequently overlooked is rhinitis. Asthma patients with significant rhinitis are over four times more likely to have poorly controlled asthma than those without. Over 80% of patients with asthma have rhinitis, which may be allergic or inflammatory/non-allergic. Both types of rhinitis share pathophysiological similarities with eosinophilic asthma, cause bronchial hyper-reactivity, and are predisposing factors for the subsequent development of asthma. Nasal allergen challenge in allergic rhinitis results in inflammation in the bronchi as well as the nose, and the reverse is also true. This article reviews briefly the evidence for the link between asthma and rhinitis, advocates looking for rhinitis when patients present with poorly controlled asthma, and provides guidance for the diagnosis and treatment of rhinitis.

Population-based study of multiplexed IgE sensitization in relation to asthma, exhaled nitric oxide, and bronchial responsiveness

BACKGROUND

IgE sensitization is an important risk factor for the development of asthma.

OBJECTIVE

The aim of this study was to investigate the IgE antibody profile for a broad spectrum of allergen molecules in asthmatic patients.

METHODS

Participants from the European Community Respiratory Health Survey II (n=467) were tested with ImmunoCAP ISAC against 103 allergen molecules. The presence of bronchial hyperresponsiveness was measured with a methacholine challenge test and bronchial inflammation with fraction of exhaled nitric oxide (Feno).

RESULTS

A total of 38% of the controls and 72% of the asthmatic patients were sensitized against at least 1 of the allergen components (P<.0001). Asthma was independently related to having IgE antibodies against pollen (odds ratio=2.2) and perennial airway allergens (odds ratio=5.6), increased Feno was independently related to having IgE antibodies against food allergens and perennial allergens, while bronchial responsiveness was independently associated with having IgE antibodies against only perennial allergens. Sensitization to food allergens was related to asthma and increased Feno if IgE antibody against pollen allergens was present. Simultaneous sensitization to perennial, pollen, and food allergens involves the highest risk of asthma (odds ratio=18.3), bronchial inflammation, and responsiveness.

CONCLUSIONS

Feno, bronchial responsiveness, and the risk of asthma increase with multiple sensitizations to different allergen groups. We show for the first time that the presence of IgE antibodies against food allergens is independently associated with increased Feno and increases the risk of asthma in subjects with simultaneous sensitization to pollen allergens.

Spirometric abnormalities in patients with allergic rhinitis: Indicator of an "asthma march"?

BACKGROUND

Allergic rhinitis (AR) may precede and promote the onset of asthma. However, few studies addressed this issue mainly concerning bronchial physiological parameters. The aim of this study was to assess forced expiratory flow at 25-75% (FEF(25-75)), forced expiratory volume at 1 second (FEV(1)), and response to bronchodilation test in a large group of AR patients.

METHODS

Sixteen hundred five adult AR patients were evaluated. Clinical examination, assessment of nasal obstruction perception by visual analog scale, spirometry, and bronchodilation test were performed in all patients.

RESULTS

There were 8.4% of patients with abnormal FEV(1) values, 24.7% had impaired FEF(25-75), and 66.1% had reversibility with bronchodilation. A trend of spirometric impairment seems to exist in these patients. Age, gender, and duration of rhinitis may be risk factors for these findings. Different grades of bronchial impairment seem to exist.

CONCLUSION

This study highlights the close link between upper and lower airways and suggests the possible existence of a progression from AR toward asthma, such as an "asthma march." Therefore, asthma should be suspected and carefully investigated in AR patients.

The prevalence of rhinitis and its association with smoking and obesity in a nationwide survey of Japanese adults

BACKGROUND

Rhinitis is a common disease, and its prevalence is increasing worldwide. Several studies have provided evidence of a strong association between asthma and rhinitis. Although smoking and obesity have been extensively analyzed as risk factors of asthma, associations with rhinitis are less clear.

OBJECTIVE

The aims of our study were (i) to evaluate the prevalence of rhinitis using the European Community Respiratory Health Survey (ECRHS) questionnaire in Japanese adults and (ii) to evaluate the associations of smoking and body mass index (BMI) with rhinitis.

METHODS

Following our study conducted in 2006-2007 to determine the prevalence of asthma using the ECRHS questionnaire, our present analysis evaluates the prevalence of rhinitis and its association with smoking and BMI in Japanese adults 20-79 years of age (N = 22819). We classified the subjects (20-44 or 45-79 years) into four groups as having (i) neither rhinitis nor asthma; (ii) rhinitis without asthma; (iii) asthma without rhinitis; or (iv) rhinitis with asthma. We then evaluated associations with smoking and BMI in each group.

RESULTS

The overall age-adjusted prevalence of rhinitis was 35.1% in men and 39.3% in women. A higher prevalence was observed in the younger population than in the older population. Active smoking and obesity were positively associated with asthma without rhinitis. In contrast, particularly in the 20- to 44-year age-group, active smoking and obesity were negatively associated with rhinitis without asthma.

CONCLUSION

The results of the present study suggest that smoking and obesity may have different effects on the development of rhinitis and asthma.

Is FENO50 useful diagnostic tool in suspected asthma?

BACKGROUND

Asthma diagnosis is based on the presence of symptoms and the demonstration of airflow variability. Airway inflammation measured by fractional exhaled nitric oxide, measured at a flow rate of 50 ml/s (FE(NO50)) remains a controversial diagnostic tool.

AIM

To assess the ability of FE(NO50) to identify bronchial hyperresponsiveness (BHR) to methacholine (provocative concentration of methacholine causing a 20% fall in FEV(1); PC20M ≤ 16 mg/ml) and to establish whether or not symptoms relate to FE(NO50) and PC20M in patients with no demonstrated reversibility to β(2) -agonist.

METHODS

We conducted a prospective study on 174 steroid naive patients with respiratory symptoms, forced expiratory volume in 1 s (FEV(1) ) ≥ 70% predicted and no demonstrated reversibility to β(2) -agonist. Patients answered to a standardised symptom questionnaire and underwent FE(NO50) and methacholine challenge. Receiver-operating characteristic (ROC) curve and logistic regression analysis assessed the relationship between PC20M and FE(NO50) , taking into account covariates (smoking, atopy, age, gender and FEV(1)).

RESULTS

A total of 82 patients had a PC20M ≤ 16 mg/ml and had significantly higher FE(NO50) (19 ppb vs. 15 ppb; p < 0.05). By constructing ROC curve, we found that FE(NO50) cut-off value of 34 ppb was able to identify not only BHR with high specificity (95%) and positive predictive value (88%) but low sensitivity (35%) and negative predictive value (62%). When combining all variables into the logistic model, FE(NO50) (p = 0.0011) and FEV(1) (p < 0.0001) were independent predictors of BHR whereas age, gender, smoking and atopy had no influence. The presence of diurnal and nocturnal wheezing was associated with raised FE(NO50) (p < 0.001 and p < 0.05, respectively).

CONCLUSION

The value of FE(NO50) > 34 ppb has high predictive value of PC20M < 16 in patients with suspected asthma in whom bronchodilating test failed to demonstrate reversibility or was not indicated. However, FE(NO50) ≤ 34 ppb does not rule out BHR and should prompt the clinician to ask for a methacholine challenge.

The burden of allergic rhinitis and asthma

Asthma and allergic rhinitis are common health problems that cause major illness and disability worldwide. The prevalence of allergic rhinitis is estimated to range from 10% to 20% in the USA and Europe. Multiple factors contribute to the wide range of reported prevalence rates. These include type of prevalence rate reported (current or cumulative), study selection criteria, age of participants, differences in survey methods, varied geographic locations and socioeconomic status, any of which are significant enough to confound direct comparison between studies. There is no standard set of diagnostic criteria for allergic rhinitis. In most studies, the criteria for diagnosis are based on the subject's reporting, solely by questionnaire and rarely confirmed by skin testing. In addition, most studies focus on hay fever, leaving perennial allergic rhinitis underestimated. Sinus imaging is generally not performed and, therefore, rhinosinusitis not differentiated. Some investigators report 'current' prevalence while others report 'cumulative' or 'lifetime' prevalence. Epidemiologic studies have consistently shown that asthma and rhinitis often coexist in the same patients. The prevalence of asthma is <2% in subjects without rhinitis while it varies from 10% to 40% in patients with rhinitis. Furthermore, the majority of patients with asthma experience rhinitis, which is a factor in the risk for asthma. Despite recognition that allergic rhinitis and asthma are global health problems, there are insufficient epidemiologic data and more data are needed with regard to their etiologic risk factors and natural history. This aim of this review is to enable the reader to discuss prevalence, risk factors and prognosis of allergic rhinitis and asthma.

FEF(25-75) might be a predictive factor for bronchial inflammation and bronchial hyperreactivity in adolescents with allergic rhinitis

Allergic rhinitis and asthma are closely associated. Bronchial hyperreactivity (BHR) is a pathophysiological characteristic of asthma. Allergic inflammation is characterized by eosinophilic infiltrate and may by indirectly assessed by exhaled nitric oxide (FeNO). Forced expiratory flow between 25 percent and 75 percent of vital capacity (FEF25-75) may predict BHR in adult patients with allergic rhinitis. The aim of this study was to evaluate the presence of BHR in a large group of adolescents with allergic rhinitis and whether FEF25-75 might be related with BHR and FeNO. Methods 150 adolescents with allergic rhinitis were enrolled. Clinical examination, skin prick test, spirometry, methacholine challenge, and FeNO were performed in all patients. Results Severe BHR is quite frequent in allergic adolescents. Impaired FEF25-75 values (such as less than 65 percent of predicted) constitute a relevant predictive factor for severe BHR (OR 4.4). FeNO levels were significantly related with BHR. Conclusion This study provides evidence that impaired FEF25-75 values might predict severe BHR and BHR is related with FeNO in adolescents. Therefore, BHR should be suspected in adolescents with low FEF25-75 values.

Impact of allergic rhinitis on bronchi: an 8-year follow-up study

BACKGROUND

Allergic rhinitis is considered a strong risk factor for the onset of asthma. However, few studies addressed this issue from a functional point of view. The aim of this study was to follow up a group of patients with allergic rhinitis to investigate the onset of possible spirometric abnormalities and/or bronchial hyperreactivity (BHR).

METHODS

Eighty-nine patients with moderate-severe persistent allergic rhinitis were prospectively and consecutively evaluated; 940 controls were also included in the study. Clinical examination, skin-prick test, spirometry, and methacholine challenge were performed in all patients every 2 years for 8 years.

RESULTS

The number of patients with forced expiratory flow at 25 and 75% of pulmonary volume of <70% of predicted significantly increased during the observation time. At baseline, no subjects had BHR; whereas 34 patients had BHR after 8 years. Sensitization to mites, birch, and Parietaria as well as rhinitis duration are risk factors for these changes.

CONCLUSION

This study highlights the close link between upper and lower airways and suggests that spirometry should be performed in patients with allergic rhinitis.

Smoking and asthma: disentangling their mutual influences using a longitudinal approach

BACKGROUND

The association between smoking and asthma remains unclear and has mostly been assessed in cross-sectional studies, with potential selection bias ("healthy smoker effect").

AIMS

Using a longitudinal approach, the aims were to assess whether 1) childhood asthma modifies smoking initiation, 2) active smoking influences asthma incidence in adults and 3) active smoking among subjects with asthma influences the persistence of the disease or the 12-year evolution in lung function in children and adults.

METHODS

Subjects (513 children and 1190 adults) were recruited and followed-up for 12 years in the context of the EGEA study (Epidemiological study on the Genetics and Environment of Asthma).

RESULTS

Childhood asthma was not associated with a decreased probability of starting active smoking (Hazard Ratio, HR = 0.96; 95% confidence interval (CI): 0.72, 1.27). Smoking at baseline was associated with a higher risk for asthma incidence in adulthood (HR = 1.95, 95% CI: 1.00, 3.77). Among subjects with asthma, smoking was unrelated to lung function evolution; however, among children with moderate to severe asthma at inclusion, smoking tended to slow down the lung function growth (P = 0.04).

CONCLUSION

These findings support the hypothesis that childhood asthma does not prevent smoking initiation and confirm that active smoking has a deleterious role on asthma. Altogether this study emphasizes the importance of active smoking as a serious public health problem particularly for children and women.

Bronchodilation test in patients with allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) may be considered a risk factor for the onset of asthma. Recently, it has been reported that forced expiratory flow between 25% and 75% of vital capacity (FEF₂₅₋₇₅) may predict a positive response to bronchodilation test in asthmatic children. The aim of this study was to evaluate a large group of adult AR patients to investigate the frequency of response to bronchodilation test and FEF₂₅₋₇₅ values.

METHODS

One thousand four hundred and sixty-nine consecutive patients suffering from persistent AR were evaluated. Clinical examination, spirometry, and bronchodilation test were performed in all patients.

RESULTS

In this study, 62.9% of patients had reversibility to bronchodilation test and 17.8% had impaired FEF₂₅₋₇₅ values (≤ 65% of predicted). Impaired FEF₂₅₋₇₅ values associated with longer rhinitis duration may predict reversibility to bronchodilation test (OR = 11.3; P < 0.001). In addition, a FEF₂₅₋₇₅ cutoff value ≤ 71% of predicted may already discriminate patients with reversibility.

CONCLUSIONS

This study highlights that about two-thirds of patients with persistent AR may be considered at risk of becoming asthmatic. This finding should be adequately considered as a precocious spirometry may allow the early detection of patients prone to develop asthma and consequently to treat them.

Effect of area of residence on patterns of aeroallergen sensitization in atopic patients

BACKGROUND

An association with sensitization to inhaled allergens and allergic rhinitis and asthma has been established. A recent study concluded that the disparity in allergen sensitization might primarily be caused by environmental factors rather than genetic differences. The primary objective was to identify potential differences in sensitization among subjects with the same ethnicity in South India who reside in different environments.

METHODS

Five hundred forty-six patients presenting to a tertiary allergy center with allergic rhinitis and or asthma underwent evaluation using a structured questionnaire, skin-prick testing to common aeroallergens, and spirometry and were categorized according to area of residence.

RESULTS

The most common allergens causing sensitization were house-dust mite (range, 65-70%), trees (range, 52-56%), and cockroaches (range, 39-53%). There was lower risk of sensitization to cockroach allergens for subjects <21 years old living in suburban (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.12-0.81) and rural environments (OR, 0.33; 95% CI, 0.11-0.96) compared with subjects <21 years old living in urban areas. There was higher risk of sensitization to fungi in subjects <21 years old living in suburban areas (OR, 1.51; 95% CI, 0.60-3.77) and rural environments (OR, 2.71; 95% CI, 0.98-7.48) compared with subjects <21 years old living in urban environments.

CONCLUSION

Sensitization patterns are similar in different areas of residence except in younger subjects. Sensitization to fungi was higher in younger subjects from the rural area and cockroach sensitization were higher in younger subjects from urban areas. Sensitization is an important precursor of clinical allergic disease and further studies to unravel the complex gene-environment interactions of aeroallergen sensitization in different environments are needed.

Relationship between bronchial hyperreactivity and bronchodilation in patients with allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) may be considered a risk factor for the onset of asthma. Recently, it has been reported that forced expiratory flow between 25% and 75% of vital capacity (FEF(25%-75%)) may predict a positive response to bronchodilation test in asthmatic children. Moreover, bronchial hyperreactivity (BHR) is frequently detected in AR patients.

OBJECTIVE

To evaluate the possible relationship between the response to bronchodilation test and methacholine challenge, also considering the FEF(25%-75%) values in a large group of patients with persistent allergic rhinitis.

METHODS

Three hundred sixty-five consecutive AR patients were evaluated. Clinical examination, spirometry, methacholine bronchial challenge, and bronchodilation test were performed in all patients.

RESULTS

Two hundred forty-one patients (66%) had "positive" results for bronchodilation test; FEF(25%-75%) was abnormal in 78 patients (21.4%), and 76 patients (20.8%) had severe BHR. An FEF(25%-75%) cutoff value of less than 58.5% of predicted may optimally (AUC 0.97) discriminate patients with both severe BHR and reversibility.

CONCLUSION

This study confirms previous studies and increases the strength of the role of FEF(25%-75%) as a marker of early bronchial involvement in patients suffering from persistent allergic rhinitis. Moreover, an FEF(25%-75%) value less than 58.5% of predicted may suggest the co-existence of severe BHR and reversibility.

Acoustic rhinometry, spirometry and nitric oxide in relation to airway allergy and smoking habits in an adolescent cohort

OBJECTIVE

This study aimed to analyze upper and lower airway function and the impact of smoking habits in a cohort of allergic and healthy adolescents. The influence of smoking habits on the outcomes of rhinitis and asthma is well documented, but only few reports are available showing smoke related upper airway impairment by rhinometric measurements, and none with focus on early changes in adolescents.

METHODS

A cohort followed from infancy was re-examined at the age of 18 years concerning allergy development. Acoustic rhinometry (VOL2), spirometry (FEV(1)) and measurements of nitric oxide levels from the upper (nNO) and lower airways (eNO) were performed before and after physical exercise, and smoking habits were registered.

RESULTS

Active smoking habits were reported by 4/21 subjects suffering from allergic rhinitis, by 1/4 from probable allergic rhinitis, by 0/3 subjects with atopic dermatitis and by 2/10 healthy controls. Smoking habits were reported as daily by 2 and occasional by 5 of the 7 active smokers. VOL2 did not increase in smokers after exercise as in non-smokers, resulting in a post-exercise group difference (7.3±1.1cm(3) vs. 8.8±1.5cm(3); p=0.02), and FEV(1) values were lower in smokers compared to non-smokers (89±7% vs. 98±8%; p=0.02). The nNO and eNO levels were, however, only slightly reduced in smokers. Airway allergy was discerned only in subjects with current allergen exposure by increased eNO levels compared to healthy controls (41±44ppb vs. 13±5ppb). The levels of VOL2, nNO and FEV(1) did not differentiate allergic subjects from healthy controls.

CONCLUSIONS

Low levels of tobacco smoke exposure resulted in reduced airway functions in this adolescent cohort. Acoustic rhinometry and spirometry were found to be more sensitive methods compared to nitric oxide measurements in early detection of airway impairment related to smoke exposure. A possible difference in airway vulnerability between allergic and healthy subjects due to smoke exposure remains to be evaluated in larger study groups.

Exhaled nitric oxide in children with allergic rhinitis and/or asthma: a relationship with bronchial hyperreactivity

BACKGROUND

Nowadays, the measure of the fractional concentration of exhaled nitric oxide (FeNO) enables to assess airway inflammation during an office visit and there is international consensus on this testing methodology. The aim of this study was to evaluate whether FeNO measurement is predictable for bronchial hyperreactivity (BHR) in children with allergic rhinitis, asthma, or both.

METHODS

Two hundred and eighty children with allergic rhinitis, allergic asthma, or both were evaluated. Bronchial function (FEV₁ and FEF(25-75)), BHR (assessed by methacholine challenge), FeNO, and sensitizations were assessed.

RESULTS

Bronchial function, BHR, and FeNO were significantly different in the three groups (p < .001). A strong inverse correlation between FeNO and BHR was found in patients with asthma and with asthma and rhinitis (r = -0.63 and r = -0.61, respectively). A cutoff of 32 ppb of FeNO was a predictive factor for BHR.

CONCLUSIONS

This study highlights the relevance of FeNO as possible marker for BHR in allergic children and underlines the close link between upper and lower airways.

Temporal relationship of allergic rhinitis with asthma and other co-morbidities in a Mediterranean country: a retrospective study in a tertiary reference allergy clinic

BACKGROUND

Allergic rhinitis is a global health problem which causes major illness and represents a risk factor for asthma. The primary aim of the study was to record the clinical pattern of allergic rhinitis and its temporal relation with asthma in a Greek population.

METHODS

Three-hundred and sixteen subjects with documented diagnosis of allergic rhinitis in a two-year period were included in this study. All participants completed a standardised questionnaire with full retrospective epidemiological data for rhinitis; in addition, serum IgE measurement and skin prick tests with 22 common inhalant allergens were carried out, while spirometry was performed in subjects with self-reported or doctor-diagnosed asthma. All subjects with at least one positive skin test were included in study analysis.

RESULTS

One-hundred and sixty five out of 316 patients (49.1%) stated self reported-asthma while in 63/316 (19.9%) asthma was documented with spirometry. One hundred out of 165 (60.6%) had rhinitis as first clinical manifestation while in 24/165 (14.5%) asthma symptoms appeared first; the remaining 31/165 (24.9%) reported simultaneous onset of upper and lower airways' symptoms. About 68.5% were sensitised to seasonal allergens exclusively, while 50% were sensitised to ≥ 1 of Parietaria, grasses sp., Olea eur. The duration of rhinitis in the subpopulation of patients with self-reported asthma (n=165) was significantly higher compared with non-asthmatics (mean=3.22 years, p<0.001). Survival analysis for the estimation of asthma onset showed that the mean time interval with rhinitis only is 16.6 years (median 12 years, incidence 0.0596).

CONCLUSIONS

The unique environmental conditions and the aerobiology of each area clearly affect the clinical features of respiratory allergy.

Lower airways may also be affected in asymptomatic patients with recent onset of allergic rhinitis

OBJECTIVES/HYPOTHESIS

It is well known that there is a close association between allergic rhinitis (AR) and asthma, and AR is a strong risk factor for the onset of asthma. AR duration is significantly associated with a possible bronchial involvement. The aim of this study was to investigate the presence of possible spirometric abnormalities and bronchial hyperreactivity (BHR) in a large group of patients with recent onset of AR.

STUDY DESIGN

Observational cross-sectional study.

METHODS

A total of 1,539 AR patients were consecutively evaluated. Clinical examination, skin prick test, spirometry, and methacholine challenge were performed on all patients.

RESULTS

: There were 362 (23%) patients with FEF(25-75) values <70% of predicted. The methacholine challenge was positive in 74.43% of patients, and 72.22% of the population presented a polysensitization. At multivariable analysis, an FEV(1) value lower than 92% of predicted, as well as increasing severity of BHR and polysensitization appeared to be independent predictors of a reduced FEF(25-75) value.

CONCLUSIONS

This study shows that reduced FEF(25-75) values may be present in some patients with recent onset of AR. FEV(1) <92%, severity of BHR, and polysensitization may be considered risk factor for this phenomenon.

Is physician-diagnosed allergic rhinitis a risk factor for the development of asthma?

BACKGROUND

There is strong evidence that there is a relationship between allergic rhinitis (AR) and asthma, but it is unclear whether there is a causal relation between AR and asthma. The aim of this study was to assess prospectively whether AR is a risk factor for the diagnosis of asthma in a large primary care population.

METHODS

We performed a historic cohort study of life-time morbidity that had been recorded prospectively since 1967 in four general practices. Two groups of subjects were selected: (i) patients with diagnosis of AR, (ii) a control group matched using propensity scores. We assessed the risk of physician-diagnosed asthma in patients with physician-diagnosed AR compared to subjects without a diagnosis of AR (controls).

RESULTS

The study population consisted of 6491 subjects (n = 2081 patients with AR). Average study follow-up was 8.4 years. In patients with AR, the frequency of newly diagnosed asthma was 7.6% (n = 158) compared to 1.6% (n = 70) in controls (P < 0.001). After adjusting the effect of AR on asthma diagnosis for registration time, age, gender, eczema and socioeconomic status, having AR was a statistically significant risk factor for asthma (hazard ratio: 4.86, P < 0.001, 95% confidence interval: 3.50-6.73, controls as reference).

CONCLUSION

A diagnosis of AR was an independent risk factor for asthma in our primary care study population. Having physician-diagnosed AR increased the risk almost fivefold for a future asthma diagnosis.

Risk factors associated with allergic and non-allergic asthma in adolescents

INTRODUCTION

Risk factors for asthma have been investigated in a large number of studies in adults and children, with little progress in the primary and secondary prevention of asthma. The aim of this investigation was to investigate risk factors associated with allergic and non-allergic asthma in adolescents.

METHODS

In this study, 959 schoolchildren (13-14 years old) answered a questionnaire and performed exhaled nitric oxide (NO) measurements. All children (n = 238) with reported asthma, asthma-related symptoms and/or increased NO levels were invited to a clinical follow-up which included a physician evaluation and skin-prick testing.

RESULTS

Asthma was diagnosed in 96 adolescents, whereof half had allergic and half non-allergic asthma. Children with both allergic and non-allergic asthma had a significantly higher body mass index (BMI) (20.8 and 20.7 vs. 19.8 kg/m(2)) (p < 0.05) and a higher prevalence of parental asthma (30% and 32% vs. 16%) (p < 0.05). Early-life infection (otitis and croup) [adjusted odds ratio (OR) (95% confidence interval (CI)): 1.99 (1.02-3.88) and 2.80 (1.44-5.42), respectively], pets during the first year of life [2.17 (1.16-4.04)], window pane condensation [2.45 (1.11-5.40)] and unsatisfactory school cleaning [(2.50 (1.28-4.89)] was associated with non-allergic but not with allergic asthma.

CONCLUSION

This study indicates the importance of distinguishing between subtypes of asthma when assessing the effect of different risk factors. While the risk of both allergic and non-allergic asthma increased with increasing BMI, associations between early-life and current environmental exposure were primarily found in relation to non-allergic asthma.

Importance of allergic rhinitis management in achieving asthma control: ARIA update

Asthma continues to be a major burden for the health and healthcare of people worldwide. The recent updates of the Global Initiative for Asthma and the National Heart, Lung and Blood Institute asthma guidelines stress the need for achieving and monitoring asthma 'control', emphasizing the importance of identifying, assessing and treating comorbid conditions. Allergic rhinitis (AR) is a major comorbid condition in people with asthma and is related to inflammation of the upper portions of the airway. Recognizing and treating AR has been shown to improve asthma control, specifically by decreasing rates of asthma attacks or asthma exacerbations. In 2008, updated Allergic Rhinitis in Asthma (ARIA) guidelines were published. The updated version of the guidelines has a familiar look, with classification systems and care algorithms that are similar to those presented in other asthma guidelines. The new ARIA guidelines make one major change that should affect the care of adults and children with asthma: everyone with asthma should be assessed for AR. In addition, AR should be considered a risk factor for asthma, and all children and adults with AR, especially persistent AR, should be assessed for asthma, including testing lung function for reversible obstruction whenever feasible. Treatment for AR follows a similar format to that for asthma, including symptom management, treatment of chronic inflammation, identification and management of triggers, including allergens, and ongoing education for self-management. Pharmacotherapies that address both asthma and AR include corticosteroids (intranasal and inhaled), leukotriene receptor antagonists, immunomodulation or immunotherapy. Too often, pharmacotherapy is not supplemented by the necessary education and evaluation related to allergen, trigger identification and management.

Phenotypes of obstructive lung disease

Recently, there has been much emphasis on the fact that there are many different phenotypes in asthma and chronic obstructive pulmonary disease (COPD). The aim of this review is to investigate some aspects of phenotyping in these two diseases. Epidemiological studies show a quite different risk factor pattern in allergic and non-allergic asthma. Several studies also indicated that there are pathophysiological differences between these two types of asthma: such as eosinophil inflammation in allergic and neutrophil predominance in non-allergic asthma. Neutrophil inflammation may also be a marker of severe asthma. At least one study indicates that non-allergic asthmatics are less responsive to inhaled corticosteroids than allergic asthmatics. Recently, it has been emphasized that COPD also has manifestations other than lung function decline and that this also needs to be taken into account in severity characterisation. Dyspnea, weight loss, psychological status and co-morbidity are factors that seem to be of large prognostic importance independently of the level of airflow obstruction in COPD. Progress has been made in understanding how asthma develops, but effective measures for primary prevention is still lacking. Better phenotyping in asthma will hopefully enable us to make progress in this area. Phenotyping is also important for assessment of prognosis in both asthma and COPD.

High BMI is related to higher incidence of asthma, while a fish and fruit diet is related to a lower- Results from a long-term follow-up study of three age groups in Sweden

The causes of the worldwide increase in asthma seen during the last decades remain largely unexplained, but lifestyle and diet are suggested to play important roles. In this follow up of a large-scale population sample in Sweden, we wanted to identify modifiable risk factors for the cumulative incidence over a 13-year follow-up period. In 1990, a self-administered questionnaire was completed by 12,560 individuals from three age groups (16, 30-39 and 60-69 years of age) in two counties of Sweden. In 2003, the eligible subjects (n = 11,282) were sent a new postal questionnaire. In total 8150 (response rate 73%) answered the questionnaire. The prevalence of asthma in 2003 had increased in all ages. In the young adults, the asthma prevalence rose from 11.3% in 1990 to 25.0% in 2003. Adult asthma onset was identified in 791 of the participants. Smoking [RR (95% CI) = 1.37 (1.12-1.68)], BMI [1.49 (1.25-1.77 per inter quartile range)], and nocturnal gastro-oesophageal reflux (GOR) [2.16 (1.72-2.72)] were significant independent risk factors for the cumulative incidence of asthma. The impact of risk factors differed between the age groups where BMI and GOR had a significantly higher impact in the middle aged and the elderly (p < 0.05). High consumption of fruit and fish was protective especially in the elderly [0.52 (0.35-0.77)]. No significant difference was found in the impact of risk factors between men and women. Weight loss, smoking cessation and a diet rich in fruit and fish may be of importance in preventing onset of adult asthma.

Asthma and rhinoconjunctivitis comorbidity: united airway disease or inherited target organs?

The idea of a united airway disease for asthma and rhinoconjunctivitis is supported by clinical and epidemiological data. However, many asthmatics do not have rhinoconjunctivitis and vice versa. The aim of this study was to investigate if the family history of a specific organ involvement is associated with the implication of the same organ in the allergic child. According to the organ involvement in either or both parents, the family history of 739 children who were skin prick positive to either Dermatophagoides pteronyssinus or D. farinae or both was defined as: asthma and rhinoconjunctivitis positive; asthma and rhinoconjunctivitis negative; asthma negative and rhinoconjunctivitis positive; and asthma positive and rhinoconjunctivitis negative. Asthma and rhinoconjunctivitis in the children were defined according to the International Study of Asthma and Allergies in Childhood questionnaire. Associations between each type of family history and the presence of asthma and/or rhinoconjunctivitis in the children were calculated and adjusted for usual confounders. Adjusted odds ratio of children having asthma, when family history included asthma, was 2.48 (1.38-4.45) when it also included rhinoconjunctivitis; and 2.13 (1.12-4.05) when it did not. However, family history of rhinoconjunctivitis was not associated with asthma in the child. Conversely, the odds ratio of children having rhinoconjunctivitis when family history included rhinoconjunctivitis was 1.84 (1.05-3.21) when it also included asthma; and 1.89 (1.23-2.89) when it did not. Family history of asthma was not associated with rhinoconjunctivitis in the child. In a population of children sensitized to mites, the organ or organs (nose and/or lung) which are implicated in parents tend to be also involved in their children.

Impact of allergic rhinitis on asthma in children: effects on bronchodilation test

BACKGROUND

Relevant relationship exists between upper and lower airways. Bronchial obstruction is a paramount feature of asthma and its reversibility is considered a diagnostic step for asthma diagnosis.

OBJECTIVE

This study aimed at evaluating a large group of children with allergic rhinitis alone for investigating the degree of brochodilation and possible factors related to it.

METHODS

Two hundred patients with allergic rhinitis and 150 normal subjects were consecutively evaluated. Clinical examination, skin prick test, spirometry, and bronchodilation test were performed in all patients.

RESULTS

Rhinitics showed a significant FEV(1) increase after bronchodilation test (P < 0.0001) in comparison both to basal values and to controls' levels. More than 20% of rhinitics had reversibility (> or =12% basal levels). Patients with reversibility had lower FEV(1) levels, longer rhinitis duration, and perennial allergy.

CONCLUSION

This study highlights the close link between upper and lower airways and the relevance of performing bronchodilation test in patients with allergic rhinitis and these characteristics.

Gender-related interactive effect of smoking and rural/urban living on asthma prevalence: a longitudinal Canadian NPHS study

The effects of passive smoking on asthma are well documented, however there is limited research conducted to study the relationship of asthma and smoking among adult populations. This article aims to investigate the gender differences when studying the relationship of asthma prevalence and smoking and further explore if rural/urban living affects the relationship over time. The longitudinal National Population Health Survey (NPHS) dataset was used. For analytic purposes five time periods were used. Generalized estimating equation (GEE) approach was used to obtain the odds ratios and 95% confidence intervals. A total of 11,223 participants ranging in age from 18 to 64; 5,382 men and 5,841 women, were included in the baseline time point (1994-1995). Rural/urban living for the present analysis was an effect modifier for the relationship of asthma prevalence and smoking, and this was true only for women. The results showed that female smokers and ex-smokers residing in rural locations were 1.4 times (95% CI: Rural Smokers = 1.02-1.94, and Rural Ex-smokers = 1.02-2.02) more likely to be diagnosed with asthma compared to non-smoking urban women. Results indicate that the combination of living in a rural area and smoking increases the risk of asthma prevalence among women but not among men.