Home Environmental Interventions for the Prevention or Control of Allergic and Respiratory Diseases: What Really Works

Revised ISHAM-ABPA working group clinical practice guidelines for diagnosing, classifying and treating allergic bronchopulmonary aspergillosis/mycoses

BACKGROUND

The International Society for Human and Animal Mycology (ISHAM) working group proposed recommendations for managing allergic bronchopulmonary aspergillosis (ABPA) a decade ago. There is a need to update these recommendations due to advances in diagnostics and therapeutics.

METHODS

An international expert group was convened to develop guidelines for managing ABPA (caused by Aspergillus spp.) and allergic bronchopulmonary mycosis (ABPM; caused by fungi other than Aspergillus spp.) in adults and children using a modified Delphi method (two online rounds and one in-person meeting). We defined consensus as ≥70% agreement or disagreement. The terms "recommend" and "suggest" are used when the consensus was ≥70% and <70%, respectively.

RESULTS

We recommend screening for A. fumigatus sensitisation using fungus-specific IgE in all newly diagnosed asthmatic adults at tertiary care but only difficult-to-treat asthmatic children. We recommend diagnosing ABPA in those with predisposing conditions or compatible clinico-radiological presentation, with a mandatory demonstration of fungal sensitisation and serum total IgE ≥500 IU·mL-1 and two of the following: fungal-specific IgG, peripheral blood eosinophilia or suggestive imaging. ABPM is considered in those with an ABPA-like presentation but normal A. fumigatus-IgE. Additionally, diagnosing ABPM requires repeated growth of the causative fungus from sputum. We do not routinely recommend treating asymptomatic ABPA patients. We recommend oral prednisolone or itraconazole monotherapy for treating acute ABPA (newly diagnosed or exacerbation), with prednisolone and itraconazole combination only for treating recurrent ABPA exacerbations. We have devised an objective multidimensional criterion to assess treatment response.

CONCLUSION

We have framed consensus guidelines for diagnosing, classifying and treating ABPA/M for patient care and research.

Fungal Colonization of the Airways of Patients with Cystic Fibrosis: the Role of the Environmental Reservoirs

Filamentous fungi frequently colonize the airways of patients with cystic fibrosis and may cause severe diseases, such as the allergic bronchopulmonary aspergillosis. The most common filamentous fungi capable to chronically colonize the respiratory tract of the patients are Aspergillus fumigatus and Scedosporium species. Defining the treatment strategy may be challenging, the number of available drugs being limited and some of the causative agents being multiresistant microorganisms. The knowledge of the fungal niches in the outdoor and indoor environment is needed for understanding the origin of the contamination of the patients. In light of the abundance of some of the causative molds in compost, agricultural and flower fields, occupational activities related to such environments should be discouraged for patients with cystic fibrosis (CF). In addition, the microbiological monitoring of their indoor environment, including analysis of air and dust on surfaces, is essential to propose preventive measures aiming to reduce the exposure to environmental molds. Nevertheless, some specific niches were also identified in the indoor environment, in relation with humidity which favors the growth of thermotolerant molds. Potted plants were reported as indoor reservoirs for Scedosporium species. Likewise, Exophiala dermatitidis may be spread in the kitchen via dishwashers. However, genotype studies are still required to establish the link between dishwashers and colonization of the airways of CF patients by this black yeast. Moreover, as nothing is known regarding the other filamentous fungi associated with CF, further studies should be conducted to identify other potential specific niches in the habitat.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Ensuring equitable access to guideline-based asthma care across the lifespan: Tips and future directions to the successful implementation of the new NAEPP 2020 guidelines, a Work Group Report of the AAAAI Asthma, Cough, Diagnosis, and Treatment Committee

The most recent recommendations from the 2020 National Asthma Education and Prevention Program Update and Global Initiative for Asthma 2021 guide evidence-based clinical decision making. However, given the present state of health disparities by age, income, and race, the equitable implementation and dissemination of these guidelines will be unlikely without further guidance. This work group report reviews the current state of the new asthma guideline implementation; presents updated evidence-based therapeutic options with attention to specific patient populations; and addresses barriers to the implementation of these guidelines in minoritized, historically marginalized, and underresourced communities. Allergists and immunologists can use practical ways to accomplish the goals of improved asthma care access and advanced asthma care across the life span, with specific considerations to historically marginalized populations. Modifiable barriers to guideline implementation include financial barriers, environmental factors, and allergy subspecialty access and care coordination. Various programs to improve access to guideline-based asthma care include community programs, school-based asthma programs, and digital health solutions, with an emphasis on reducing disparities by race.

Environmental Interventions for Asthma

Exposure and sensitization to environmental factors play a fundamental role in asthma development and is strongly associated with asthma morbidity. While hereditary factors are critical determinants of asthma, exposures to environmental factors are implicated in the phenotypic expression of asthma and have been strongly associated in the risk of its development. Significant interest has thus been geared toward potentially modifiable environmental exposures which may lead to the development of asthma. Allergen exposure, in particular indoor allergens, plays a significant role in the pathogenesis of asthma, and remediation is a primary component of asthma management. In the home, multifaceted and multitargeted environmental control strategies have been shown to reduce home exposures and improve asthma outcomes. In addition to the home environment, assessment of the school, daycare, and workplace environments of patients with asthma is necessary to ensure appropriate environmental control measures in conjunction with medical care. This article will discuss the role of the environment on asthma, review targeted environmental therapy, and examine environmental control measures to suppress environmental exposures in the home and school setting.

The role of environmental allergen control in the management of asthma

Allergen exposure may exacerbate asthma symptoms in sensitized patients. Allergen reduction or avoidance measures have been widely utilized; however, there is ongoing controversy on the effectiveness of specific allergen control measures in the management of children with asthma. Often, allergen avoidance strategies are not recommended by guidelines because they can be complex or burdensome, although individual patients may benefit. Here we explore the potential for intervention against exposure to the major allergens implicated in asthma (ie, house dust mites, indoor molds, rodents, cockroaches, furry pets, and outdoor molds and pollens), and subsequent effects on asthma symptoms. We critically assess the available evidence regarding the clinical benefits of specific environmental control measures for each allergen. Finally, we underscore the need for standardized and multifaceted approaches in research and real-life settings, which would result in the identification of more personalized and beneficial prevention strategies.

2021 Brazilian Thoracic Association recommendations for the management of severe asthma

Advances in the understanding that severe asthma is a complex and heterogeneous disease and in the knowledge of the pathophysiology of asthma, with the identification of different phenotypes and endotypes, have allowed new approaches for the diagnosis and characterization of the disease and have resulted in relevant changes in pharmacological management. In this context, the definition of severe asthma has been established, being differentiated from difficult-to-control asthma. These recommendations address this topic and review advances in phenotyping, use of biomarkers, and new treatments for severe asthma. Emphasis is given to topics regarding personalized management of the patient and selection of biologicals, as well as the importance of evaluating the response to treatment. These recommendations apply to adults and children with severe asthma and are targeted at physicians involved in asthma treatment. A panel of 17 Brazilian pulmonologists was invited to review recent evidence on the diagnosis and management of severe asthma, adapting it to the Brazilian reality. Each of the experts was responsible for reviewing a topic or question relevant to the topic. In a second phase, four experts discussed and structured the texts produced, and, in the last phase, all experts reviewed and approved the present manuscript and its recommendations.

Knowledge, attitudes, and practices concerning cockroach exposure among caregivers of children with asthma

Background

Cockroach allergen is one of the most important asthma triggers for children. There is an extensive body of research on interventions to reduce exposure. However, adherence to these interventions is low. Insight into the knowledge, attitudes, and practices (KAP) associated with cockroach remediation is needed. We assessed KAP using the Health Beliefs Model (HBM) as a framework for predicting behavior. This study aimed to assess the socio-demographic and psycho-social characteristics associated with cockroach KAP and to quantify the relationship between KAP and number of cockroaches in the home.

Methods

To identify factors associated with cockroach KAP a cross-sectional study was conducted using a structured questionnaire administered to caregivers of children with asthma in New Orleans, Louisiana. Positive scores in each metric of the KAP signified better cockroach knowledge, increased concern about cockroaches’ impact on health (attitudes), and participation in recommended cockroach remediation practices (practices). To evaluate cockroach KAP scores as a predictor of cockroach exposure in the home, a cohort study was conducted among a sub-sample of participants.

Results

Fifty-six caregivers participated in the study. Participants had positive scores on all subscales of KAP with knowledge having a lower score compared to attitudes and practices. Cockroach knowledge was inversely correlated with age at asthma diagnosis (ρ = − 0.36, p = 0.01). Caregivers identifying as black/African American had higher cockroach knowledge scores compared to other races (Median: 6.0 v 3.0; p = 0.05). Caregivers other than mothers had higher cockroach attitude scores (Median 6.5 v 4.0; p = 0.003) and total KAP scores (Median 18.0 v 14.0; p = 0.05). Twenty-six participants completed the cohort study. Cockroach exposure was not significantly associated with higher cockroach knowledge, cockroach practice, or total KAP score. For attitude scores, participants in the highest quartile had significantly lower exposure (β: -1.96, 95% CI: − 3.50 - 0.42) compared to those in the lowest quartile (p = 0.01).

Conclusions

Different socio-demographic and psycho-social factors were associated with the components of cockroach KAP. Greater concern about cockroaches (attitude) was significantly associated with reduced cockroach exposure. This highlights the importance of identifying the key elements of caregiver KAP to improve cockroach remediation among caregivers of children with asthma.

[Hypersensitivity Pneumonitis: An update]

Hypersensitivity Pneumonitis (HP) is a common immune-mediated interstitial lung disease (ILD) induced by repeated exposure to environmental antigens in susceptible individuals. The most commonly known forms are bird fancier's disease and farmer's lung. However, the antigens involved are widely diverse. Therefore, the list of causes of HP is frequently expanding. HP seems to be under-diagnosed owing to its highly heterogeneous presentation in both the non-fibrotic and fibrotic subtypes and could represent up to 15% of all ILDs encountered in clinical practice. However, the recognition of HP cases is essential to ensure appropriate therapy for the patient. Home health care workers' intervention is sometimes critical in this context. In case of confirmed exposure, the diagnosis could be considered with high confidence if the high-resolution computed tomography (HR-CT) shows a typical HP pattern associated with a lymphocytosis over 30% in the broncho-alveolar lavage (BAL). In all other situations, the patients should undergo further investigations and additional histopathological sampling should be considered and submitted to a multidisciplinary team discussion. After diagnosis, antigenic eviction is the rule whenever possible. Corticosteroid treatment is the first-line medical treatment for severe forms and aims to prevent the development of fibrosis. Anti-fibrotic therapy is now an option for patients with progressive ILD and failure of immunomodulatory/immunosuppressive therapies.

Changes in children's respiratory morbidity and residential exposure factors over 25 years in Chongqing, China

Background

Respiratory morbidity and mortality during childhood remains a major challenge for global health. Due to the rapid economic development in Chongqing, we expect substantial temporal changes in respiratory health status and environmental risk factors in children. By leveraging a historical dataset, this study aims to assess the changes in prevalence of respiratory symptoms and diseases, residential exposure factors, and their associations in school-age children over a period of 25 years.

Methods

This study involved two cross-sectional surveys conducted in Chongqing with a 25-year interval (2017 vs. 1993). Purpose sampling was used to conduct questionnaire surveys on school-age children in both surveys. Information collected include children’s respiratory health outcomes, family residential exposures, demographic information, and parental respiratory disease history. The changes of residential exposures as well as demographics were determined by chi-square test. Odds ratios were calculated to compare the prevalence of children’s respiratory symptoms and diseases between the two periods. Associations between children’s respiratory outcomes and exposure indicators were assessed using multivariate logistic regressions.

Results

The majority of residential exposure indicators improved in 2017, including sleep in shared room, cooking with coal, poor kitchen ventilation, cooking frequency, and parental smoking. Compared to the 1993 study, the adjusted risk for children’s wheezing was lower (OR: 0.38, 95% CI: 0.29, 0.49), but the risk for bronchitis was higher (OR: 1.89, 95% CI: 1.54, 2.31) in the 2017 study. Poor kitchen ventilation and parental smoking were linked to an increased risk of children’s wheezing (OR: 1.39, 95% CI: 1.02, 1.90) and bronchitis (OR: 1.51, 95% CI: 1.02, 2.21), respectively, while heating in winter was linked to an increased risk of phlegm (OR: 1.40, 95% CI: 1.03, 1.90) and wheezing (OR: 1.47, 95% CI: 1.07, 2.01) in the 1993 study. However, these residential exposure factors were no longer associated with the children’s respiratory diseases in the 2017 study.

Conclusions

Our study found improvement of residential exposures in Chongqing, a decline of prevalence of children’s wheezing but an increase of that of bronchitis from 1993 to 2017. Poor kitchen ventilation, heating in winter, and parental smoking were significant risk factors in the 1993 survey but, with significantly reduced prevalence in 2017, were not significantly associated with children’s respiratory morbidity in the latter survey.

Screening Social Determinants of Health in a Multidisciplinary Severe Asthma Clinical Program

Supplemental Digital Content is available in the text.

Asthma is the most common cause of chronic disease in children and has high healthcare utilization costs. Minority children living in poverty have a higher asthma burden. These health disparities are associated with the social determinants of health (SDH). A severe asthma clinic was implemented at Rady Children’s Hospital in San Diego to determine whether a multidisciplinary approach, including an asthma home visit addressing SDH, would lead to decreased healthcare utilization in terms of emergency department (ED) visits and hospitalizations.

Metagenomic Characterization of Indoor Dust Bacterial and Fungal Microbiota in Homes of Asthma and Non-asthma Patients Using Next Generation Sequencing

Background

The exposure of house occupants to indoor air pollutants has increased in recent decades. Among microbiological contaminants, bacterial and fungal aerosols remain poorly studied and the debate on the impact of these aerosols on respiratory health is still open. This study aimed to assess the diversity of indoor microbial communities in relationship with the health of occupants.

Methods

Measurements were taken from dwellings of 2 cohorts in Brittany (France), one with children without any pathology and the other with children and adults with asthma. Thirty dust samples were analyzed by next generation sequencing with a 16S and 18S targeted metagenomics approach. Analysis of sequencing data was performed using qiime 2, and univariate and multivariate statistical analysis using R software and phyloseq package.

Results

A total of 2,637 prokaryotic (589 at genus level) and 2,153 eukaryotic taxa were identified (856 fungal taxa (39%) and 573 metazoa (26%)). The four main bacterial phyla were identified: Proteobacteria (53%), Firmicutes (27%), Actinobacteria (11%), Bacteroidetes (8%). Among Fungi, only 136 taxa were identified at genus level. Three main fungal phyla were identified: Ascomycota (84%), Basidiomycota (12%) and Mucoromycota (3%). No bacterial nor fungal phyla were significantly associated with asthma versus control group. A significant over representation in control group versus asthma was observed for Christensenellaceae family (p-value = 0.0015, adj. p-value = 0.033). Besides, a trend for over representation in control group was observed with Dermabacteraceae family (p-value = 0.0002, adj. p-value = 0.815).

Conclusions

Our findings provide evidence that dust samples harbor a high diversity of human-associated bacteria and fungi. Molecular methods such as next generation sequencing are reliable tools for identifying and tracking the bacterial and fungal diversity in dust samples, a less easy strategy for the detection of eukaryotes at least using18S metagenomics approach. This study showed that the detection of some bacteria might be associated to indoor air of asthmatic patients. Regarding fungi, a higher number of samples and sequencing with more depth could allow reaching significant signatures.

The Indoor Environment and Childhood Asthma

PURPOSE OF REVIEW

Sensitization and exposure to triggers in the indoor environment, including aeroallergens, indoor air pollution, and environmental tobacco smoke, have a significant role in asthma development and morbidity. This review discusses indoor environmental exposures and their effect on children with asthma as well as environmental interventions and their role in improving asthma morbidity.

RECENT FINDINGS

Recent research has emphasized the role of aeroallergen sensitization and exposure in asthma morbidity and the importance of the school indoor environment. There is an established association between indoor exposures and asthma development and morbidity. Recent evidence has highlighted the importance of the indoor environment in childhood asthma, particularly the role of the school indoor environment. While home environmental interventions have had mixed results, interventions in the school environment have the potential to significantly impact the health of children, and ongoing research is needed to determine their effectiveness.

The Clinical Utility of Pollen Counts

In this review, we describe how pollen counts are performed, the health effects caused by exposure to varying amounts of pollen, the clinical utility of reporting pollen counts to the public, and how that information can be used by patients who have allergies to improve their health. The public is very interested in pollen counts, particularly if the counts provide a forecast of expected pollen exposure for the next few days. Traditional pollen counts are labor-intensive; poorly distributed; and, since the counts are usually 1-day-old, do not provide forecasts that can be acted on. New methods that provide short- and long-term pollen forecasts can provide this information to allergic individuals so that they can respond to changing outdoor conditions. Studies of the relationship between artificial and natural exposure to pollen and development of symptoms have provided improved understanding into how much pollen it takes to cause symptoms. Thresholds for pollen counts that trigger symptoms vary by pollen type, sensitivity of the population, and interactions with other atmospheric exposures. Strategies to inform the public when the pollen count poses a health risk have been proposed along with computerized systems that provide personalized pollen alerts. The best performing public notification system was a "traffic light system" that reported pollen exposure as low, 0-30; intermediate, 31-50; or high, 51-150. This system outperformed other threshold systems used in Sweden and in Britain/Denmark. Continued improvements in pollen forecasting models combined with data provided by automated pollen counters and better public reporting should permit allergic individuals and urban planners to adapt effectively to changes in outdoor aeroallergen exposures.

The Role of Home Environments in Allergic Disease

Allergic diseases are surprisingly common, chronic health conditions. The primary location where the vast majority of people are exposed to allergens and other substances is in their home. This means it is important to understand home environments and how a home's systems function and interact-and that how we occupy these spaces plays a crucial role in both environmental exposure and management of allergic disease. This review provides an overview of what is understood about home environmental exposure and its impact on our health, and proposes a systematic process for using a patient's environmental history to develop individualized, manageable and cost-effective recommendations. Once occupant-related information has been gathered, a home environmental exposure assessment should be performed focused on identifying the relationships between any identified sources of contaminants and the housing systems, and conditions that may be contributing to exposure. The results and recommendations from this assessment can then be used to guide exposure-reduction efforts by patients and/or their caregivers in an effort to improve disease management. In this review, we'll discuss three different types of home interventions-active, which must be routinely performed by the patient and/or caregiver, passive, which are interventions that work without routine, direct interaction from the homeowner, and behavioral changes in how the home environment is cleaned and maintained for long-term reduction of allergens. In this review, and others evaluated for this discussion, a significant number of home environmental assessment and intervention programs were shown to be cost effective, with the majority of programs showing a net positive return on investment. It is important to recognize that to be cost effective, the level and intensity of services offered through home visit programs need be stratified, based on the estimated health risks of the patient, in order to tailor the assessment and target the interventions to a patient's needs while maximizing cost effectiveness.

Asthma and Indoor Environment: Usefulness of a Global Allergen Avoidance Method on Asthma Control and Exposure to Molds

The usefulness and feasibility of a global allergens avoidance method with counselors visiting patients' home for allergens measures and adapted advices were prospectively evaluated through asthma control and environment evaluation. Twenty seven patients were prospectively included and compared to a cohort of 30 control patients. The level of control of asthma at inclusion and after 1 year was evaluated by the clinical signs, the evolution of the FEV1, and the healthcare use. Environmental measurements included the fungal load of 5 surfaces of the dwellings and the evaluation of moisture. A significant clinical improvement in the population that benefited from the home counselors visit was observed compared to the baseline (p < 0.0001), as well as a decreased number of hospitalizations for asthma and of the consumption of anti-asthma drugs (p < 0.01). Dampness markers slightly improved with an improvement of the fungal loads in two-third of the dwellings.

Indoor Environmental Interventions for Furry Pet Allergens, Pest Allergens, and Mold: Looking to the Future

Over the last 2 to 3 decades, significant advances have been made in understanding the role that indoor allergen exposures play with regard to respiratory health. Multiple studies have confirmed that sensitization and exposure to indoor allergens can be a risk factor for asthma morbidity. Environmental interventions targeting key indoor allergens have been evaluated with the aims of examining their causal effects on asthma-related outcomes and identifying clinically efficacious interventions to incorporate into treatment recommendations. Historically, it appeared that the most successful intervention, as performed in the Inner-City Asthma Study, was individually tailored, targeting multiple allergens in a predominantly low-income, minority, and urban pediatric population. Recent studies suggest that single-allergen interventions may be efficacious when targeting the most clinically relevant allergen for a population. In this article, we review recent literature on home environmental interventions and their effects on specific indoor allergen levels and asthma-related outcomes.

A reintroduction of environmental mite allergen control strategies for asthma treatment and the debate on their effectiveness

Asthma affects three hundred million people worldwide. The effectiveness of house dust mite allergen control for asthma treatment is debatable. One aspect that has been little discussed in existing meta-analyses is the possible role of environmental strategies. Here, we reintroduce the previously defined strategies for mite allergen control and discuss their importance to the debate on clinical effectiveness. The strategy of concurrent bedroom interventions is related to the combined use of a priori defined interventions, while the strategy of exposure-based control relates to the treatment of relevant textiles after assessing exposure. The air purification strategy aims to purify the human breathing zone of airborne allergens. In Western European patient practice, the use of these strategies differs. A post hoc study of the dominant Cochrane review by Gøtzsche and Johansen (Cochrane Database of Systematic Reviews, 2008, Art. No: CD001187) appears to indicate that a majority of the underlying trials reported on the strategy of concurrent bedroom interventions, which were mainly executed in a minimal manner. Some trials have reported on the air purification strategy and may potentially alter the debate on effectiveness. No trial has reported on the strategy of exposure-based control. We therefore hypothesize that the absence of evidence for the effectiveness of mite allergen control for asthma treatment applies to the strategy of concurrent bedroom interventions. The evidence-based effectiveness of the exposure-based control strategy appears to be undetermined. The results of our post hoc reanalysis urge that future meta-analyses of mite allergen control should a priori define the environmental strategy under study. Future trials of mite allergen control are warranted to test the exposure-based strategy as well as the sparsely tested strategy of air purification.

Idiopathic pulmonary fibrosis: unmasking cryptogenic environmental factors

Idiopathic pulmonary fibrosis (IPF) is a progressive fibrotic lung disease of unknown origin that is associated with high morbidity and mortality. In this perspective, we briefly review the current understanding of the pathophysiology of IPF and the importance of environmental triggers as a precipitant of disease. We discuss occult intrinsic and extrinsic environmental factors that affect the lung microenvironment and may contribute to the development and progression of disease. The clinical implications of this framework need to be further elucidated, because prompt identification and elimination of occult exposures may represent a novel treatment modality.

Bedroom Allergen Exposure Beyond House Dust Mites

PURPOSE OF REVIEW

The review provides insight into recent findings on bedroom allergen exposures, primarily focusing on pet, pest, and fungal exposures.

RECENT FINDINGS

Large-scale studies and improved exposure assessment technologies, including measurement of airborne allergens and of multiple allergens simultaneously, have extended our understanding of indoor allergen exposures and their impact on allergic disease. Practical, streamlined methods for exposure reduction have shown promise in some settings, and potential protective effects of early-life exposures have been further elucidated through the investigation of specific bacterial taxa. Advances in molecular allergology have yielded novel data on sensitization profiles and cross-reactivity. The role of indoor allergen exposures in allergic disease is complex and remains incompletely understood. Advancing our knowledge of various co-exposures, including the environmental and host microbiome, that interact with allergens in early life will be crucial for the development of efficacious interventions to reduce the substantial economic and social burden of allergic diseases including asthma.

Indoor mould exposure, asthma and rhinitis: findings from systematic reviews and recent longitudinal studies

Starting from the Institute of Medicine (IOM) and World Health Organization (WHO) reports, this review provides an overview of the literature published from 2006 to 2017 on the associations between indoor mould exposure and asthma and rhinitis separately in children and adults with a focus on longitudinal epidemiological studies.A systematic search of peer-reviewed literature was performed, including systematic reviews and meta-analyses, longitudinal, incident case-control and panel studies. 61 publications were identified reporting visible mould or mould odour or quantitative assessment of culturable fungi or mould species.In children, visible mould and mould odour were associated with the development and exacerbations of asthma, providing sufficient evidence of a causal relationship. Results from population-based studies in adults were too few and divergent to conclude at more than a limited level of evidence. Exposure to mould in a work building was associated with the incidence and exacerbations of occupational asthma, and we concluded at a sufficient evidence for an association. Systematic reviews, meta-analyses and longitudinal studies on the relationships between mould exposure and allergic rhinitis provide sufficient evidence of an association.This review extended the conclusions of the IOM and WHO reports, and highlighted the need for further longitudinal studies on asthma in adults, and on rhinitis.

Indoor Environmental Interventions and their Effect on Asthma Outcomes

PURPOSE OF REVIEW

The use of environmental interventions to improve outcomes in asthmatics has long been an elusive goal. While numerous interventions have been studied, the results of clinical trials have been mixed. This review aims to identify combinations of interventions that have been proven to be effective and to propose a model for using them in a clinical setting.

RECENT FINDINGS

An NIH workshop emphasized a need for research to identify effective interventions for reducing indoor exposures and improving asthma outcomes. A number of innovative measures were described, though evidence supporting their use was lacking. A recent systematic review described various interventions for which evidence is available. The greatest challenge for this approach is the same as that for the medical approach to treatment: nonadherence. Given evidence for effective interventions, control of environmental exposures should lead to improved asthma outcomes. Methods to improve adherence need to be identified.

The Journal of Allergy and Clinical Immunology: In Practice 2017 Year in Review

An impressive number of clinically impactful studies and reviews were published in The Journal of Allergy and Clinical Immunology: In Practice in 2017. As a service to our readers, the editors provide this Year in Review article to highlight and contextualize the advances published over the past year. We include information from articles on asthma, allergic rhinitis, rhinosinusitis, immunotherapy, atopic dermatitis, contact dermatitis, food allergy, anaphylaxis, drug hypersensitivity, urticarial/angioedema, eosinophilic disorders, and immunodeficiency. Within each topic, epidemiologic findings are presented, relevant aspects of prevention are described, and diagnostic and therapeutic advances are enumerated. Treatments discussed include behavioral therapy, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We hope this review will help readers consolidate and use this extensive and practical knowledge for the benefit of patients.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

IV Brazilian Consensus on Rhinitis - an update on allergic rhinitis

INTRODUCTION

The guidelines on allergic rhinitis aim to update knowledge about the disease and care for affected patients. The initiative called "Allergic Rhinitis and its Impact on Asthma", initially published in 2001 and updated in 2008 and 2010, has been very successful in disseminating information and evidence, as well as providing a classification of severity and proposing a systemized treatment protocol. In order to include the participation of other medical professionals in the treatment of allergic rhinitis, it is important to develop algorithms that accurately indicate what should and can be done regionally.

OBJECTIVE

To update the III Brazilian Consensus on Rhinitis - 2012, with the creation of an algorithm for allergic rhinitis management.

METHODS

We invited 24 experts nominated by the Brazilian Association of Allergy and Immunology, Brazilian Association of Otorhinolaryngology and Head and Neck Surgery and Brazilian Society of Pediatrics to update the 2012 document.

RESULTS

The update of the last Brazilian Consensus on Rhinitis incorporated and adapted the relevant information published in all "Allergic Rhinitis and its Impact on Asthma" Initiative documents to the Brazilian scenario, bringing new concepts such as local allergic rhinitis, new drugs and treatment evaluation methods.

CONCLUSION

A flowchart for allergic rhinitis treatment has been proposed.

Managing Asthma in Low-Income, Underrepresented Minority, and Other Disadvantaged Pediatric Populations: Closing the Gap

PURPOSE OF REVIEW

In this article, we review current understanding of the epidemiology and etiology of disparities in asthma. We also highlight current and emerging literature on solutions to tackle disparities while underscoring gaps and pressing future directions.

RECENT FINDINGS

Tailored, multicomponent approaches including the home, school, and clinician-based interventions show great promise. Managing asthma in disadvantaged populations can be challenging as they tend to have disproportionately worse outcomes due to a multitude of factors. However, multifaceted, innovative interventions that are sustainable and scalable are key to improving outcomes.