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Prapamontol T, Norbäck D, Thongjan N, Suwannarin N, Somsunun K, Ponsawansong P, Radarit K, Kawichai S, Naksen W. Asthma and rhinitis in wet and dry season among students in upper Northern Thailand: the role of building dampness and household air pollution. INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 2022:1-13. [PMID: 35253533 DOI: 10.1080/09603123.2022.2047902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/24/2022] [Indexed: 06/14/2023]
Abstract
We investigated associations between domestic exposure and respiratory health in students inNorthern Thailand in wet and dry season (1159 participants), calculating odds ratios (OR) with 95% confidence intervals (CI) by multilevel logistic regression. Totally 6.0% had wheeze, 23.0% dyspnoea, 4.0% current asthma, 54.6% rhinitis and 31.5% rhinoconjunctivitis. Girls had less wheeze (OR 0.66; 95% CI 0.43-1.00) and current asthma (OR 0.32; 95% CI 0.19-0.54). Water leakage was associated with wheeze (OR 2.35; 95% CI 1.09-5.06), dyspnea (OR 2.00; 95% CI 1.24-3.23) and rhinoconjunctivitis (OR 1.62; 95% CI 1.11-2.38). Mould was associated with rhinitis (OR 1.89; 95% CI 1.06-3.38). Window pane condensation was associated with wheeze (OR 2.60; 95% CI 1.13-5.98) and rhinoconjunctivitis (OR 1.70; 95% CI 1.08-2.67). Biomass burning was associated with wheeze, dyspnoea, rhinitis and rhinoconjunctivitis. In conclusion, household dampness and pollution from domestic biomass burning can increase asthma symptoms and rhinitis symptoms in students in northern Thailand.
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Affiliation(s)
- Tippawan Prapamontol
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Dan Norbäck
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Nathaporn Thongjan
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Neeranuch Suwannarin
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Kawinwut Somsunun
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | - Kesseya Radarit
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Sawaeng Kawichai
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Warangkana Naksen
- Faculty of Public Health, Chiang Mai University, Chiang Mai, Thailand
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2
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Krantz C, Accordini S, Alving K, Corsico AG, Demoly P, Ferreira DS, Forsberg B, Garcia-Aymerich J, Gislason T, Heinrich J, Jõgi R, Johannessen A, Leynaert B, Marcon A, Martínez-Moratalla Rovira J, Nerpin E, Nowak D, Olin AC, Olivieri M, Pereira-Vega A, Raherison-Semjen C, Real FG, Sigsgaard T, Squillacioti G, Janson C, Malinovschi A. Cross-sectional study on exhaled nitric oxide in relation to upper airway inflammatory disorders with regard to asthma and perennial sensitization. Clin Exp Allergy 2021; 52:297-311. [PMID: 34536262 DOI: 10.1111/cea.14019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 09/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) is a well-known marker of type-2 inflammation. FeNO is elevated in asthma and allergic rhinitis, with IgE sensitization as a major determinant. OBJECTIVE We aimed to see whether there was an independent association between upper airway inflammatory disorders (UAID) and FeNO, after adjustment for asthma and sensitization, in a multi-centre population-based study. METHODS A total of 741 subjects with current asthma and 4155 non-asthmatic subjects participating in the second follow-up of the European Community Respiratory Health Survey (ECRHS III) underwent FeNO measurements. Sensitization status was based on measurement of IgE against airborne allergens; information on asthma, UAID and medication was collected through interview-led questionnaires. Independent associations between UAID and FeNO were assessed in adjusted multivariate regression models and test for interaction with perennial sensitization and asthma on the relation between UAID and FeNO were made. RESULTS UAID were associated with higher FeNO after adjusting for perennial sensitization, asthma and other confounders: with 4.4 (0.9-7.9) % higher FeNO in relation to current rhinitis and 4.8 (0.7-9.2) % higher FeNO in relation to rhinoconjunctivitis. A significant interaction with perennial sensitization was found in the relationship between current rhinitis and FeNO (p = .03) and between rhinoconjunctivitis and FeNO (p = .03). After stratification by asthma and perennial sensitization, the association between current rhinitis and FeNO remained in non-asthmatic subjects with perennial sensitization, with 12.1 (0.2-25.5) % higher FeNO in subjects with current rhinitis than in those without. CONCLUSIONS & CLINICAL RELEVANCE Current rhinitis and rhinoconjunctivitis was associated with higher FeNO, with an interaction with perennial sensitization. This further highlights the concept of united airway disease, with correlations between symptoms and inflammation in the upper and lower airways and that sensitization needs to be accounted for in the relation between FeNO and rhinitis.
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Affiliation(s)
- Christina Krantz
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Simone Accordini
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Kjell Alving
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Angelo G Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation, Pavia, Italy.,Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Pascal Demoly
- Département de Pneumologie et Addictologie, Centre Hospitalier Universitaire de Montpellier, Montpellier, France.,Hôpital Arnaud de Villeneuve, IDESP, INSERM-Univ Montpellier, Montpellier, France
| | - Diogenes S Ferreira
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia.,Alergia e Imunologia, Complexo Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Bertil Forsberg
- Department of Public Health and Clinical Medicine, Section of Sustainable Health, Umeå University, Umeå, Sweden
| | - Judith Garcia-Aymerich
- ISGlobal, Barcelona, Spain.,Universitat Pompeu Fabra (UPF), Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Thorarinn Gislason
- Department of Sleep, Landspitali_the National University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Joachim Heinrich
- Institute and Clinic for Occupational, Social and Environmental Medicine, LMU University Clinic, Comprehensive Pneumology Center (CPC), Munich, Germany.,German Center for Lung Research (DZL), Gießen, Germany.,Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Vic., Australia
| | - Rain Jõgi
- Lung Clinic, Tartu University Hospital, Tartu, Estonia
| | - Ane Johannessen
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Bénédicte Leynaert
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, INSERM, Équipe d'Épidémiologie respiratoire intégrative, CESP, Villejuif, France
| | - Alessandro Marcon
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Jesús Martínez-Moratalla Rovira
- Pneumology Service of the University Hospital of Albacete, Albacete, Spain.,Faculty of Medicine of Albacete, Castilla-La Mancha University, Albacete, Spain
| | - Elisabet Nerpin
- Department of Medical Sciences, Respiratory Medicine, Allergy and Sleep, Uppsala University, Uppsala, Sweden.,Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden.,Department of Medicine, Health and Social Studies, Dalarna University, Falun, Sweden
| | - Dennis Nowak
- Institute and Clinic for Occupational, Social and Environmental Medicine, LMU University Clinic, Comprehensive Pneumology Center (CPC), Munich, Germany.,German Center for Lung Research (DZL), Gießen, Germany
| | - Anna-Carin Olin
- Section of Occupational and Environmental Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Mario Olivieri
- Unit of Occupational Medicine, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | | | - Chantal Raherison-Semjen
- Univ. Bordeaux, INSERM, Bordeaux, France.,Service des Maladies Respiratoires, Pole cardio-thoracique, CHU, Bordeaux, France
| | - Francisco Gómez Real
- Research Unit for Health Surveys (RUHS), Department of Clinical Sciences, University of Bergen, Bergen, Norway.,Department of Gynaecology and Obstetrics, Haukeland University Hospital, Bergen, Norway
| | - Torben Sigsgaard
- Department of Public Health, Danish Ramazzini Center, Aarhus University, Aarhus, Denmark
| | - Guilia Squillacioti
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Christer Janson
- Department of Medical Sciences, Respiratory Medicine, Allergy and Sleep, Uppsala University, Uppsala, Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
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3
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Prapamontol T, Norbäck D, Thongjan N, Suwannarin N, Somsunun K, Ponsawansong P, Khuanpan T, Kawichai S, Naksen W. Fractional exhaled nitric oxide (FeNO) in students in Northern Thailand: associations with respiratory symptoms, diagnosed allergy and the home environment. J Asthma 2021; 59:1787-1795. [PMID: 34435554 DOI: 10.1080/02770903.2021.1968424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE There are few studies on fractional exhaled nitric oxide (FeNO) among children in subtropical areas. We studied associations between FeNO and respiratory symptoms, reported diagnosed allergies and indoor and outdoor environmental factors in first grade junior high school students (N = 270) in upper northern Thailand. METHODS Data on demographics, health and home environment were collected by a questionnaire distributed in dry season (February-March 2018). FeNO was measured when the research team visited the school. Daily outdoor pollution data (PM10 and ozone) were collected from the nearest monitoring station 3 days (lag 3) and 7 days (lag 7) before the FeNO measurements. Two-level (student, school) linear mixed models were used to analyze associations, adjusting for gender and family education level. RESULTS In total, 29.6% had elevated FeNO level (>20 ppb) and 7.8% reported any allergy diagnosed by a doctor. Male gender (p = 0.02), diagnosed allergy (p = 0.001), especially to cat (p = 0.001) and house dust mite (HDM) allergies (p = 0.001) were associated with FeNO. Eye symptoms (p = 0.01), rhinitis symptoms (p = 0.03) and dyspnea (p = 0.05) in the last 3 days were associated with FeNO. Household indoor mold (p = 0.03), gas cooking (p = 0.03) and PM10 (lag 3 and lag 7) were negatively (protective) associated with FeNO. CONCLUSIONS Diagnosed allergy, especially to cat and HDM, can be associated with increased FeNO. Indoor mold and gas cooking can be associated with lower FeNO. Ocular, nasal and dyspnea symptoms reported by students in dry season in northern Thailand can be associated with FeNO, a biomarker of Th2 driven airway inflammation.
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Affiliation(s)
- Tippawan Prapamontol
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Dan Norbäck
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand.,Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Nathaporn Thongjan
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Neeranuch Suwannarin
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Kawinwut Somsunun
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | - Tosabhorn Khuanpan
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Sawaeng Kawichai
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Warangkana Naksen
- Faculty of Public Health, Chiang Mai University, Chiang Mai, Thailand
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4
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Jang YY, Ahn JY. Evaluation of Fractional Exhaled Nitric Oxide in Pediatric Asthma and Allergic Rhinitis. CHILDREN-BASEL 2020; 8:children8010003. [PMID: 33374635 PMCID: PMC7822451 DOI: 10.3390/children8010003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/09/2020] [Accepted: 12/21/2020] [Indexed: 11/30/2022]
Abstract
Fractional exhaled nitric oxide (FeNO) is a non-invasive test for evaluating the degree of airway inflammation and for the diagnosis, evaluation, and treatment of asthma. We attempted to measure FeNO levels in Korean children with asthma and determine its cutoff value for diagnosing asthma. We enrolled 176 children and adolescents between the ages of 5 and 18 years, who visited for the evaluation of chronic cough, shortness of breath, and wheezing. Among them, 138 patients who underwent skin prick tests or inhalation Immuno CAP (UniCAP; Pharmacia, Uppsala, Sweden) tests for allergy testing together with a pulmonary function test were included. FeNO was measured using a NIOX MINO (Aerocrine AB, Solna, Sweden) instrument according to the American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines. There were 29 patients with asthma, 43 with rhinitis, and 38 with asthma and allergic rhinitis. In the asthma group, FeNO levels significantly correlated with total immunoglobulin E (r = 0.572, p < 0.001), but did not show significant correlation with pulmonary function test parameters (forced vital capacity—FVC, forced expiratory volume in one second—FEV1, FEV1/FVC) or PC20 (provocative concentration of methacholine causing a 20% fall in FEV1). The FeNO cutoff values obtained in the asthma and asthma rhinitis groups were 16.5 ppb and 18.5 ppb, respectively. Hence, we provide a FeNO cutoff value according to the presence or absence of rhinitis in pediatric patients with asthma.
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Affiliation(s)
- Yoon Young Jang
- Department of Pediatrics, School of Medicine, Daegu Catholic University Medical Center, Daegu 42472, Korea;
| | - Ji Young Ahn
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu 38541, Korea
- Correspondence: ; Tel.: +82-53-620-3536; Fax: +82-53-620-4459
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Heffler E, Carpagnano GE, Favero E, Guida G, Maniscalco M, Motta A, Paoletti G, Rolla G, Baraldi E, Pezzella V, Piacentini G, Nardini S. Fractional Exhaled Nitric Oxide (FENO) in the management of asthma: a position paper of the Italian Respiratory Society (SIP/IRS) and Italian Society of Allergy, Asthma and Clinical Immunology (SIAAIC). Multidiscip Respir Med 2020; 15:36. [PMID: 32269772 PMCID: PMC7137762 DOI: 10.4081/mrm.2020.36] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/05/2020] [Indexed: 02/08/2023] Open
Abstract
Asthma prevalence in Italy is on the rise and is estimated to be over 6% of the general population. The diagnosis of asthma can be challenging and elusive, especially in children and the last two decades has brought evidences that asthma is not a single disease but consists of various phenotypes. Symptoms can be underestimated by the patient or underreported to the clinician and physical signs can be scanty. Usual objective measures, like spirometry, are necessary but sometimes not significant. Despite proper treatment, asthma can be a very severe condition (even leading to death), however new drugs have recently become available which can be very effective in its control. Since asthma is currently thought to be caused by inflammation, a direct measure of the latter can be of paramount importance. For this purpose, the measurement of Fractional Exhaled Nitric Oxide (FENO) has been used since the early years of the current century as a non-invasive, easy-to-assess tool useful for diagnosing and managing asthma. This SIP-IRS/SIAAIC Position Paper is a narrative review which summarizes the evidence behind the usefulness of FENO in the diagnosis, management and phenotypization of asthma.
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Affiliation(s)
- Enrico Heffler
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Rozzano (MI).,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI)
| | - Giovanna Elisiana Carpagnano
- Department of Medical and Surgical Sciences, University of Foggia; Section of Respiratory Diseases, Hospital d'Avanzo, Foggia
| | - Elisabetta Favero
- Department of Medicine-DIMED, Immunological and Respiratory Rare Disease, Allergologic Clinic Ca' Foncello Hospital, Treviso
| | - Giuseppe Guida
- Allergy and Pneumology Unit, A.O. S. Croce e Carle, Cuneo
| | - Mauro Maniscalco
- Respiratory Rehabilitation Unit, ICS Maugeri, Institute of Telese Terme IRCCS
| | - Andrea Motta
- Institute of Biomolecular Chemistry, National Research Council, Pozzuoli (NA)
| | - Giovanni Paoletti
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Rozzano (MI).,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI)
| | - Giovanni Rolla
- Allergy and Clinical Immunology, University of Turin and A.O. Mauriziano, Turin
| | - Eugenio Baraldi
- Department of Woman's and Child's Health, University Hospital of Padua
| | - Vincenza Pezzella
- Department of Woman, Child and of General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples
| | - Giorgio Piacentini
- Paediatric Section, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona
| | - Stefano Nardini
- Italian Respiratory Society-Società Italiana di Pneumologia, Milan, Italy
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6
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Zhang X, Norbäck D, Fan Q, Bai X, Li T, Zhang Y, Li B, Zhao Z, Huang C, Deng Q, Lu C, Qian H, Xu Y, Sun Y, Sundell J, Wang J. Dampness and mold in homes across China: Associations with rhinitis, ocular, throat and dermal symptoms, headache and fatigue among adults. INDOOR AIR 2019; 29:30-42. [PMID: 30379348 DOI: 10.1111/ina.12517] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 10/23/2018] [Accepted: 10/24/2018] [Indexed: 05/23/2023]
Abstract
We studied dampness and mold in China in relation to rhinitis, ocular, throat and dermal symptoms, headache and fatigue. A questionnaire study was performed in six cities including 36 541 randomized parents of young children. Seven self-reported signs of dampness were evaluated. Multilevel logistic regression models were used to calculate odds ratios (ORs). Totally, 3.1% had weekly rhinitis, 2.8% eye, 4.1% throat and 4.8% skin symptoms, 3.0% headache and 13.9% fatigue. Overall, 6.3% of the homes had mold, 11.1% damp stains, 35.3% damp bed clothing, 12.8% water damage, 45.4% window pane condensation, 11.1% mold odor, and 37.5% humid air. All dampness signs were associated with symptoms (ORs from 1.2 to 4.6; P < 0.001), including rhinitis (ORs from 1.4 to 3.2; P < 0.001), and ORs increased by number of dampness signs. The strongest associations were for mold odor (ORs from 2.3 to 4.6) and humid air (ORs from 2.8 to 4.8). Associations were stronger among men and stronger in Beijing as compared to south China. In conclusion, dampness and mold are common in Chinese homes and associated with rhinitis and ocular, throat and dermal symptoms, headache and fatigue. Men can be more sensitive to dampness and health effects of dampness can be stronger in northern China.
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Affiliation(s)
- Xin Zhang
- Institute of Environmental Science, Shanxi University, Taiyuan, China
| | - Dan Norbäck
- Institute of Environmental Science, Shanxi University, Taiyuan, China
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Qiannan Fan
- Institute of Environmental Science, Shanxi University, Taiyuan, China
| | - Xu Bai
- Institute of Environmental Science, Shanxi University, Taiyuan, China
| | - Tian Li
- Institute of Environmental Science, Shanxi University, Taiyuan, China
| | - Yinping Zhang
- School of Architecture, Tsinghua University, Beijing, China
| | - Baizhan Li
- Key Laboratory of Three Gorges Reservoir Region's Eco-Environment, Chongqing University, Chongqing, China
| | - Zhuohui Zhao
- Department of Environmental Health, Fudan University, Shanghai, China
| | - Chen Huang
- Department of Building Environment and Energy Engineering, School of Environment and Architecture, University of Shanghai for Science and Technology, Shanghai, China
| | - Qihong Deng
- XiangYa School of Public Health, Central South University, Changsha, China
- School of Energy Science and Engineering, Central South University, Changsha, China
| | - Chan Lu
- XiangYa School of Public Health, Central South University, Changsha, China
- School of Energy Science and Engineering, Central South University, Changsha, China
| | - Hua Qian
- School of Energy & Environment, Southeast University, Nanjing, China
| | - Yang Xu
- College of Life Sciences, Central China Normal University, Wuhan, China
| | - Yuexia Sun
- School of Environmental Science and Engineering, Tianjin University, Tianjin, China
| | - Jan Sundell
- School of Environmental Science and Engineering, Tianjin University, Tianjin, China
| | - Juan Wang
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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7
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Dávila I, Domínguez‐Ortega J, Navarro‐Pulido A, Alonso A, Antolín‐Amerigo D, González‐Mancebo E, Martín‐García C, Núñez‐Acevedo B, Prior N, Reche M, Rosado A, Ruiz‐Hornillos J, Sánchez MC, Torrecillas M. Consensus document on dog and cat allergy. Allergy 2018; 73:1206-1222. [PMID: 29318625 DOI: 10.1111/all.13391] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2017] [Indexed: 12/16/2022]
Abstract
The prevalence of sensitization to dogs and cats varies by country, exposure time and predisposition to atopy. It is estimated that 26% of European adults coming to the clinic for suspected allergy to inhalant allergens are sensitized to cats and 27% to dogs. This document is intended to be a useful tool for clinicians involved in the management of people with dog or cat allergy. It was prepared from a consensus process based on the RAND/UCLA method. Following a literature review, it proposes various recommendations concerning the diagnosis and treatment of these patients, grounded in evidence and clinical experience. The diagnosis of dog and cat allergy is based on a medical history and physical examination that are consistent with each other and is confirmed with positive results on specific IgE skin tests. Sometimes, especially in polysensitized patients, molecular diagnosis is strongly recommended. Although the most advisable measure would be to avoid the animal, this is often impossible and associated with a major emotional impact. Furthermore, indirect exposure to allergens occurs in environments in which animals are not present. Immunotherapy is emerging as a potential solution to this problem, although further supporting studies are needed.
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Affiliation(s)
- I. Dávila
- Allergy Department University Hospital of Salamanca Salamanca Spain
- Institute for Biomedical Research IBSAL Salamanca Spain
- Department of Biomedical and Diagnostic Sciences University of Salamanca Salamanca Spain
| | - J. Domínguez‐Ortega
- Allergy Department Hospital La Paz Institute for Health Research (IdiPAZ) Madrid Spain
- CIBER de Enfermedades Respiratorias (CIBERES) Madrid Spain
| | - A. Navarro‐Pulido
- Allergology Clinical Management Unit (UGC) El Tomillar Hospital Sevilla Spain
| | - A. Alonso
- Allergy Department Valladolid Medical Alliance Valladolid Spain
| | - D. Antolín‐Amerigo
- Immune System Diseases Department‐Allergy Unit Príncipe de Asturias University Hospital Madrid Spain
- Department of Medicine and medical specialties (IRYCIS) University of Alcalá Madrid Spain
| | | | | | | | - N. Prior
- Allergy Department Severo Ochoa University Hospital Madrid Spain
| | - M. Reche
- Allergy Department Infanta Sofía Hospital Madrid Spain
| | - A. Rosado
- Allergy Unit Alcorcón Foundation University Hospital Madrid Spain
| | | | - M. C. Sánchez
- Allergy Unit Juan Ramón Jiménez Hospital Huelva Spain
| | - M. Torrecillas
- Allergy Department Albacete University General Hospital Complex Albacete Spain
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8
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Norbäck D, Lu C, Zhang Y, Li B, Zhao Z, Huang C, Zhang X, Qian H, Sundell J, Deng Q. Common cold among pre-school children in China - associations with ambient PM 10 and dampness, mould, cats, dogs, rats and cockroaches in the home environment. ENVIRONMENT INTERNATIONAL 2017; 103:13-22. [PMID: 28351766 DOI: 10.1016/j.envint.2017.03.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 03/16/2017] [Accepted: 03/16/2017] [Indexed: 06/06/2023]
Abstract
BACKGROUND There is some evidence that dampness, mould and cockroaches can increase the risk of respiratory infections in children but few studies exist from China on this topic. Aim To study associations between domestic early life exposure to biological indoor factors (dampness, mould, cats, dogs, rats, cockroaches), cleaning habits and common cold among pre-school children across China. METHODS Children aged 3-6years (n=39,782) were recruited from randomly selected day care centres in seven cities in China. Data on common cold and prenatal and postnatal exposure to dampness, mould, windowpane condensation in wintertime (WPC), cats, dogs, cockroaches and rats were assessed by a parentally administered questionnaire. Data on annual ambient temperature and PM10 was assessed on city level. Associations between high frequency (>5 colds per year) and long duration (≥2weeks) of common colds in the past year and exposure were calculated by multilevel logistic regression. RESULTS A total of 9.2% had a high frequency and 11.9% had long duration of common cold. Exposure to mould (OR=1.38, 95% CI 1.24-1.53) and WPC (OR 1.23, 95%CI 1.13-1.33) at birth was associated with frequent common cold. Exposure to dogs at birth was associated with long duration of common cold. (OR=1.22, 95% CI 1.06-1.41). Exposure to mould (OR=1.36, 95% CI 1.22-1.54), WPC (OR=1.27, 95%CI 1.17-1.39) and water leakage (OR 1.34, 95% CI 1.20-1.49) in the current home was associated with frequent common cold. Presence of cockroaches were positively (OR=1.12, 95% CI 1.02-1.24) and presence of rats (OR=0.86, 95% CI 0.77-0.96) negatively associated with high frequency of common cold. Daily cleaning was negatively associated with frequent common cold (OR=0.89, 95% CI 0.81-0.97). Similar associations for mould, WPC, cockroaches and rats were found for long duration. Ambient PM10 (OR=1.21, 95% CI 1.21-1.35 per 10μg/m3) and temperature (OR=1.13, 95% CI 1.06-1.35 °C) on city level were associated with high frequency of common cold. Associations between cat keeping and high frequency of common cold were found only in southern China. Associations with cockroaches were stronger in northern China. Associations with dampness and mould were the same in the north and south. CONCLUSIONS Indoor mould, water damage, windowpane condensation, cockroaches and keeping cats or dogs as pets can be risk factors for common cold while daily cleaning can be protective factor. PM10 and a warmer climate zone can be other risk factors for common cold.
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Affiliation(s)
- Dan Norbäck
- School of Energy Science and Engineering, Central South University, Changsha, Hunan, China; Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
| | - Chan Lu
- School of Energy Science and Engineering, Central South University, Changsha, Hunan, China
| | - Yinping Zhang
- School of Architecture, Tsinghua University, Beijing, China
| | - Baizhan Li
- Key Laboratory of Three Gorges Reservoir Region's Eco-Environment, Chongqing University, Chongqing, China
| | - Zhuohui Zhao
- Department of Environmental Health, Fudan University, Shanghai, China
| | - Chen Huang
- School of Environment and Architecture, University of Shanghai for Science and Technology, Shanghai, China
| | - Xin Zhang
- Research Center for Environmental Science and Engineering, Shanxi University, Taiyuan, China
| | - Hua Qian
- School of Energy & Environment, Southeast University, Nanjing, China
| | - Jan Sundell
- School of Energy Science and Engineering, Central South University, Changsha, Hunan, China; School of Architecture, Tsinghua University, Beijing, China
| | - Qihong Deng
- School of Energy Science and Engineering, Central South University, Changsha, Hunan, China; XiangYa School of Public Health, Central South University, Changsha, Hunan, China.
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Cipriani F, Calamelli E, Ricci G. Allergen Avoidance in Allergic Asthma. Front Pediatr 2017; 5:103. [PMID: 28540285 PMCID: PMC5423906 DOI: 10.3389/fped.2017.00103] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 04/21/2017] [Indexed: 01/31/2023] Open
Abstract
Allergic asthma is the most frequent disease among the chronic respiratory disorders in pediatric age with an important social impact. In the last years, many efforts have been made to identify effective preventive approaches to get a better control of symptoms and to obtain the best future outcomes for the patients. In patients with allergic asthma triggered by the exposure to indoor allergens, the avoidance is the first intervention to prevent the appearance or the worsening of bronchial symptoms. This review article summarized the most recent evidence from literature about the efficacy of specific control interventions for the most important allergens. Even if a wide spectrum of interventions has been suggested and may help to reduce exposure to trigger allergy for sensitized patients suffering from respiratory allergy, evidence supporting the efficacy of these approaches is still weak and subject of controversy. However, the exposure control to specific airborne allergens is still widely recommended and may be effective as part of a holistic approach to reduce the severity of allergic respiratory symptoms in sensitized individuals.
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Affiliation(s)
- Francesca Cipriani
- Pediatric Unit, S. Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elisabetta Calamelli
- Pediatric Unit, S. Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Pediatric and Neonatology Unit, Imola Hospital, Bologna, Italy
| | - Giampaolo Ricci
- Pediatric Unit, S. Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Takaoka M, Suzuki K, Norbäck D. Current asthma, respiratory symptoms and airway infections among students in relation to the school and home environment in Japan. J Asthma 2017. [PMID: 28635545 DOI: 10.1080/02770903.2016.1255957] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To study associations between the school and home environment and current asthma, respiratory symptoms and airway infections among Japanese students. METHODS Japanese students (12-15 y) (N = 1048) in four schools responded to a questionnaire on respiratory health, allergy and the home environment. Temperature, relative air humidity (RH) and student density (students/m2 floor area) was measured in the classrooms: dust was collected from floors and in classroom air and analysed for cat (Fel d 1) and dog (Can f 1) allergens. Health associations were analysed by multi-level logistic regression. RESULTS Doctor's diagnosed asthma was common (13.4%), 8.8% reported cat allergy and 6.1% dog allergy. The median level in floor dust was 41 ng/g (IQR 23-92) for Fel d 1 and 101 ng/g (IQR 54-101) for Can f 1. The median level in air was 18.6 ng/ m2/ day (IQR5.9-25.1) for Fel d 1 and 18.6 ng/ m2/ day (IQR 6.0-13.3) for Can f 1. High RH, high student density and airborne cat allergen was associated with airway infections. In the home environment, recent indoor painting, new floor materials, odour, having cats as pets, window pane condensation in winter, and dampness in floor construction were associated with respiratory illness. CONCLUSION High relative air humidity, high student density and airborne cat allergens at school may increase the risk of airway infections. Having cats as pets, chemical emissions from paint and new floor materials, odour and dampness can constitute domestic risk factors for respiratory symptoms while having dogs as pets could be protective.
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Affiliation(s)
- Motoko Takaoka
- a Department of Biosphere Sciences , School of Human Sciences, Kobe College , Nishinomiya Hyogo , Japan
| | - Kyoko Suzuki
- a Department of Biosphere Sciences , School of Human Sciences, Kobe College , Nishinomiya Hyogo , Japan
| | - Dan Norbäck
- b Department of Medical Sciences , Occupational and Environmental Medicine, Uppsala University and University Hospital , Uppsala , Sweden
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NIOX VERO: Individualized Asthma Management in Clinical Practice. Pulm Ther 2016. [DOI: 10.1007/s41030-016-0018-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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12
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Association of symptom control with changes in lung function, bronchial hyperresponsiveness, and exhaled nitric oxide after inhaled corticosteroid treatment in children with asthma. Allergol Int 2016; 65:439-443. [PMID: 27160342 DOI: 10.1016/j.alit.2016.03.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 03/14/2016] [Accepted: 03/30/2016] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND A key therapeutic approach to asthma, which is characterized by chronic airway inflammation, is inhaled corticosteroid (ICS). This study evaluated the association of symptom control with changes in lung function, bronchial hyperresponsiveness (BHR), and exhaled nitric oxide (eNO) after ICS treatment in asthmatic children. METHODS A total of 33 children aged between 5 and 12 years with mild to moderate persistent asthma were treated with 160 μg ciclesonide per day for 3 months. At days 0 and 90, the following parameters were assessed: asthma symptom scores; lung function, including forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and forced expiratory flow at 25-75% of forced vital capacity (FEF25-75%); BHR to methacholine and adenosine 5-monophosphate (AMP); and eNO. RESULTS Asthma symptom scores, lung function parameters, BHR to methacholine and AMP, and eNO levels at day 90 were significantly improved versus day 0 (all p < 0.001). Symptom scores at day 90 were not correlated with changes in lung function and BHR to methacholine during the follow-up period, whereas those at day 90 were more closely correlated with changes in BHR to AMP (r = 0.511, p = 0.003) than with eNO (r = -0.373, p = 0.035). Additionally, changes in PC20 AMP were correlated with changes in PC20 methacholine (r = 0.451, p = 0.011) and eNO (r = -0.474, p = 0.006). CONCLUSIONS Changes in the BHR to AMP, and to a lesser extent eNO, correlate with asthma symptom control after ICS treatment. BHR to AMP may better reflect the relationship between improved airway inflammation due to ICS treatment and asthma symptoms.
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Jacinto T, Alving K, Correia R, Costa-Pereira A, Fonseca J. Setting reference values for exhaled nitric oxide: a systematic review. CLINICAL RESPIRATORY JOURNAL 2016; 7:113-20. [PMID: 22789005 DOI: 10.1111/j.1752-699x.2012.00309.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The values obtained when the fraction of exhaled nitric oxide (FeNO) is measured are affected by several factors that are specific to the individual patient, making interpretation difficult, especially in the initial assessment of patients with respiratory symptoms. METHODS Systematic review of studies on FeNO reference values and individual-specific factors that influence them. RESULTS From 3739 references, 15 studies were included. Four studies included children and adolescents. In nine studies, samples were selected from the general population. Most studies reported objective measures for atopy (nine studies), but not for smoking status (one). Significant determinants of FeNO values reported were age and height (seven studies), atopy (six), smoking (four), weight (four), sex (three) and race (three). Additional factors were included in eight studies. R2 was reported in only five studies. The logarithmic transformation of FeNO was inadequately described in seven studies. CONCLUSION There are several equations for FeNO reference values that may be used in clinical practice, although the factors they include and the statistical methods they use vary considerably. We recommend the development of standard methods for the evaluation of normal FeNO data and that reference equations should be formulated based on a predetermined physiological model.
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Affiliation(s)
- Tiago Jacinto
- CINTESIS – Center for Research in Health Technologies and Information Systems, Faculty of Medicine, University of Porto, Porto, Portugal.
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Lee YK, Yang S, Park J, Kim H, Hahn YS. House dust mite-specific immunoglobulin E and longitudinal exhaled nitric oxide measurements in children with atopic asthma. KOREAN JOURNAL OF PEDIATRICS 2015; 58:89-95. [PMID: 25861331 PMCID: PMC4388976 DOI: 10.3345/kjp.2015.58.3.89] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 10/10/2014] [Accepted: 10/30/2014] [Indexed: 11/27/2022]
Abstract
Purpose House dust mite (HDM) has been suggested to be the most important aeroallergen responsible for atopic asthma in Korea. We aimed to investigate that specific IgE antibodies to HDM and other common indoor aeroallergens contribute differently to total serum IgE and show different relationships with longitudinal fractional exhaled nitric oxide (FeNO) measurements in Korean atopic asthmatic patients. Methods A total of 193 children aged 8 to 16 years with intermittent or mild persistent atopic asthma were recruited. Sera were assayed for total IgE and specific IgE antibodies to HDM and other common indoor allergens. FeNO was serially measured 10 times or more over 2 years when subjects were not receiving controller medications. Results In 152 children who completed the study, IgE antibodies to specific HDM were more prevalent than those to other common indoor aeroallergens. In addition, IgE antibody titers to HDM were the strongest contributor to total IgE increases. Furthermore, only HDM-specific IgE antibody titer significantly correlated with maximum FeNO (r=0.21, P=0.029) and the rate of FeNO higher than 21 parts per billion (ppb) (r=0.30, P=0.002). Eight patients (5%) were found to have maximum FeNO of 21 ppb or less, suggesting the presence of a low FeNO phenotype among atopic asthmatic patients. Conclusion The quantity of HDM-specific IgE antibody provides a possible explanation for increases of total IgE and significantly correlates with the amount and frequency of FeNO increases in Korean atopic asthmatic patients.
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Affiliation(s)
- Youn Kyung Lee
- Department of Pediatrics, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Sohyoung Yang
- Department of Pediatrics, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Joohyun Park
- Department of Pediatrics, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Heon Kim
- Department of Preventive Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Youn-Soo Hahn
- Department of Pediatrics, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
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Wang J, Engvall K, Smedje G, Norbäck D. Rhinitis, asthma and respiratory infections among adults in relation to the home environment in multi-family buildings in Sweden. PLoS One 2014; 9:e105125. [PMID: 25136984 PMCID: PMC4138153 DOI: 10.1371/journal.pone.0105125] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 07/21/2014] [Indexed: 11/18/2022] Open
Abstract
Risk factors for rhinitis, asthma and respiratory infections in the home environment were studied by a questionnaire survey. Totally 5775 occupants (≥ 18 years old) from a stratified random sample of multi-family buildings in Sweden participated (46%). 51.0% had rhinitis in the last 3 months (current rhinitis); 11.5% doctor diagnosed asthma; 46.4% respiratory infections in the last 3 months and 11.9% antibiotic medication for respiratory infections in the last 12 months. Associations between home environment and health were analyzed by multiple logistic regression, controlling for gender, age and smoking and mutual adjustment. Buildings constructed during 1960-1975 were risk factors for day time breathlessness (OR = 1.53, 95%CI 1.03-2.29). And those constructed during 1976-1985 had more current rhinitis (OR = 1.43, 95%CI 1.12-1.84) and respiratory infections (OR = 1.46, 95%CI 1.21-1.78). Cities with higher population density had more current rhinitis (p = 0.008) and respiratory infections (p<0.001). Rented apartments had more current rhinitis (OR = 1.23, 95%CI 1.07-1.40), wheeze (OR = 1.20, 95%CI 1.02-1.41), day time breathlessness (OR = 1.31, 95%CI 1.04-1.66) and respiratory infections (OR = 1.13, 95%CI 1.01-1.26). Living in colder parts of the country was a risk factor for wheeze (p = 0.03) and night time breathlessness (p = 0.002). Building dampness was a risk factor for wheeze (OR = 1.42, 95%CI 1.08-1.86) and day time breathlessness (OR = 1.57, 95%CI 1.09-2.27). Building dampness was a risk factor for health among those below 66 years old. Odor at home was a risk factor for doctor diagnosed asthma (OR = 1.49, 95%CI 1.08-2.06) and current asthma (OR = 1.52, 95%CI 1.03-2.24). Environmental tobacco smoke (ETS) was a risk factor for current asthma (OR = 1.53, 95%CI 1.09-2.16). Window panel condensation was a risk factor for antibiotic medication for respiratory infections (OR = 1.41, 95%CI 1.10-1.82). In conclusion, rhinitis, asthma and respiratory infections were related to a number of factors in the home environment. Certain building years (1961-1985), building dampness, window panel condensation and odor in the dwelling may be risk factors.
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Affiliation(s)
- Juan Wang
- Department of Medical Sciences, Uppsala University and University Hospital, Uppsala, Sweden
- * E-mail:
| | - Karin Engvall
- Department of Medical Sciences, Uppsala University and University Hospital, Uppsala, Sweden
| | - Greta Smedje
- Department of Medical Sciences, Uppsala University and University Hospital, Uppsala, Sweden
| | - Dan Norbäck
- Department of Medical Sciences, Uppsala University and University Hospital, Uppsala, Sweden
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Yao TC, Tsai HJ, Tu YL, Chang SW, Hua MC, Liao SL, Tsai MH, Chiu CY, Lai SH, Yeh KW, Huang JL. Multiplexed immunoglobulin E sensitization in relation to exhaled nitric oxide in a population sample of children. Allergy 2014; 69:678-82. [PMID: 24576320 DOI: 10.1111/all.12378] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2014] [Indexed: 11/28/2022]
Abstract
This study investigated the relationship between the specific immunoglobulin E (IgE) profile for 40 allergens using a novel microarray technique (BioIC) and fraction of exhaled nitric oxide (FeNO) in a population sample of 1321 children. Significant positive associations were found between FeNO and sensitization to mites (P < 0.001), animals (P = 0.001), cockroaches (P < 0.001), and foods (P = 0.042), and furthermore, between FeNO and the number of sensitizations (all P < 0.05) or the sum of specific IgE (all P ≤ 0.01) against the aforementioned allergen categories. Specifically, sensitization to the following allergens was significantly related to higher FeNO: Dermatophagoides pteronyssinus, Dermatophagoides farina, Blomia tropicalis, cat, German cockroach, Oriental cockroach, codfish, crab, shrimp, and cheese (all P ≤ 0.01). In conclusion, IgE sensitization to mites, pets, cockroaches, seafood, and cheese, respectively, is significantly associated with elevated FeNO levels in a dose-dependent fashion in children. Our results provide new evidence that sensitization to certain food allergens may contribute to prompt inflammation in the airways.
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Affiliation(s)
- T.-C. Yao
- Division of Allergy, Asthma, and Rheumatology; Department of Pediatrics; Chang Gung Memorial Hospital and Chang Gung University College of Medicine; Taoyuan Taiwan
- Community Medicine Research Center; Chang Gung Memorial Hospital at Keelung; Keelung Taiwan
| | - H.-J. Tsai
- Division of Biostatistics and Bioinformatics; Institutes of Population Health Sciences; National Health Research Institutes; Miaoli Taiwan
- Department of Pediatrics; Feinberg School of Medicine; Northwestern University; Chicago IL USA
- Department of Genome Medicine; Kaohsiung University; Kaohsiung Taiwan
| | - Y.-L. Tu
- Division of Allergy, Asthma, and Rheumatology; Department of Pediatrics; Chang Gung Memorial Hospital and Chang Gung University College of Medicine; Taoyuan Taiwan
- Community Medicine Research Center; Chang Gung Memorial Hospital at Keelung; Keelung Taiwan
- Graduate Institute of Clinical Medical Sciences; Chang Gung University College of Medicine; Taoyuan Taiwan
| | - S.-W. Chang
- Clinical Informatics and Medical Statistics Research Center; Chang Gung University College of Medicine; Taoyuan Taiwan
| | - M.-C. Hua
- Community Medicine Research Center; Chang Gung Memorial Hospital at Keelung; Keelung Taiwan
- Department of Pediatrics; Chang Gung Memorial Hospital at Keelung; Keelung Taiwan
| | - S.-L. Liao
- Community Medicine Research Center; Chang Gung Memorial Hospital at Keelung; Keelung Taiwan
- Department of Pediatrics; Chang Gung Memorial Hospital at Keelung; Keelung Taiwan
| | - M.-H. Tsai
- Community Medicine Research Center; Chang Gung Memorial Hospital at Keelung; Keelung Taiwan
- Department of Pediatrics; Chang Gung Memorial Hospital at Keelung; Keelung Taiwan
| | - C.-Y. Chiu
- Community Medicine Research Center; Chang Gung Memorial Hospital at Keelung; Keelung Taiwan
- Department of Pediatrics; Chang Gung Memorial Hospital at Keelung; Keelung Taiwan
| | - S.-H. Lai
- Community Medicine Research Center; Chang Gung Memorial Hospital at Keelung; Keelung Taiwan
- Division of Pediatric Pulmonology; Department of Pediatrics; Chang Gung Memorial Hospital; Taoyuan Taiwan
| | - K.-W. Yeh
- Division of Allergy, Asthma, and Rheumatology; Department of Pediatrics; Chang Gung Memorial Hospital and Chang Gung University College of Medicine; Taoyuan Taiwan
- Community Medicine Research Center; Chang Gung Memorial Hospital at Keelung; Keelung Taiwan
| | - J.-L. Huang
- Division of Allergy, Asthma, and Rheumatology; Department of Pediatrics; Chang Gung Memorial Hospital and Chang Gung University College of Medicine; Taoyuan Taiwan
- Community Medicine Research Center; Chang Gung Memorial Hospital at Keelung; Keelung Taiwan
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Patelis A, Janson C, Borres MP, Nordvall L, Alving K, Malinovschi A. Aeroallergen and food IgE sensitization and local and systemic inflammation in asthma. Allergy 2014; 69:380-7. [PMID: 24397423 DOI: 10.1111/all.12345] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2013] [Indexed: 01/09/2023]
Abstract
BACKGROUND We recently reported an independent association between IgE sensitization to food allergens and increased airway inflammation, assessed by fraction of exhaled nitric oxide (FeNO), in a population-based study (J Allergy Clin Immunol, 130, 2012, 397). Similar studies have not been performed in populations with asthma. The aim of the present study was to investigate the allergic sensitization profile in asthmatics and examine FeNO, airway responsiveness and blood eosinophilia in relation to type and degree of IgE sensitization. METHOD FeNO, airway responsiveness, blood eosinophil count (B-Eos) and IgE sensitization to food allergens and aeroallergens were determined in 408 subjects with asthma, aged 10-34 years. RESULTS Asthmatics had higher prevalence of IgE sensitization against all allergens than controls (P < 0.001). Mite, pollen, furry animal, mould and food sensitizations were each associated with increased FeNO, airway responsiveness and B-Eos in asthmatics. IgE sensitization to mould, furry animals and food allergens was independently related to FeNO (all P < 0.05) after adjustment for age, sex, height, smoking history and medication. IgE sensitization to mould (P < 0.001) and furry animals (P = 0.02) was related to airway responsiveness in a similar model. Finally, IgE sensitization to mould (P = 0.001), furry animals (P < 0.001) and food allergens (P < 0.001) was independently related to B-Eos. CONCLUSION Independent effects of IgE sensitization to aeroallergens (furry animals and mould) and food allergens were found on both local and systemic markers of inflammation in asthma. The finding regarding food IgE sensitization is novel, and a clinical implication might be that even food sensitization must be assessed to fully understand inflammation patterns in asthma.
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Affiliation(s)
- A. Patelis
- Department of Medical Sciences, Respiratory Medicine & Allergology; Uppsala University; Uppsala Sweden
| | - C. Janson
- Department of Medical Sciences, Respiratory Medicine & Allergology; Uppsala University; Uppsala Sweden
| | - M. P. Borres
- Immunodiagnostics; Thermo Fischer Scientific; Uppsala Sweden
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
| | - L. Nordvall
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
| | - K. Alving
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
| | - A. Malinovschi
- Department of Medical Sciences, Clinical Physiology; Uppsala University; Uppsala Sweden
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Hahn YS. Measurements of fractional exhaled nitric oxide in pediatric asthma. KOREAN JOURNAL OF PEDIATRICS 2013; 56:424-30. [PMID: 24244210 PMCID: PMC3827490 DOI: 10.3345/kjp.2013.56.10.424] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 08/27/2013] [Indexed: 01/19/2023]
Abstract
Exhaled nitric oxide (NO) has been extensively investigated as a noninvasive marker of airway inflammation in asthma. The increased NO expression induced by inflammatory mediators in airways can be monitored easily in exhaled air from asthmatic children. Based on the relationship between the increased NO expression and eosinophilic airway inflammation, fractional exhaled nitric oxide (FeNO) measurements become an important adjunct for the evaluation of asthma. In addition, the availability of portable devices makes it possible to measure FeNO more easily and frequently in the routine pediatric practice. Despite various confounding factors affecting its levels, FeNO can be applicable in diagnosing asthma, monitoring treatment response, evaluating asthma control, and predicting asthma exacerbations. Thus, although pulmonary function tests are the standard tools for objective measurements of asthmatic control, FeNO can broaden the way of asthma monitoring and supplement standard clinical asthma care guidelines.
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Affiliation(s)
- Youn-Soo Hahn
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
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Portnoy J, Kennedy K, Sublett J, Phipatanakul W, Matsui E, Barnes C, Grimes C, Miller JD, Seltzer JM, Williams PB, Bernstein JA, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J. Environmental assessment and exposure control: a practice parameter--furry animals. Ann Allergy Asthma Immunol 2012; 108:223.e1-15. [PMID: 22469456 DOI: 10.1016/j.anai.2012.02.015] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 02/21/2012] [Indexed: 12/20/2022]
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Portnoy J, Kennedy K, Sublett J, Phipatanakul W, Matsui E, Barnes C, Grimes C, Miller JD, Seltzer JM, Williams PB, Bernstein JA, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J. Environmental assessment and exposure control: a practice parameter--furry animals. Ann Allergy Asthma Immunol 2012. [PMID: 22469456 DOI: 10.1016/j.anai.2012.02.015.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2022]
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Grzelewski T, Majak P, Jerzyńska J, Cichalewski L, Krakowiak J, Stelmach W, Stelmach R, Janas A, Grzelewska A, Stelmach I. The association between fractional exhaled nitric oxide (FeNO) and cat dander in asthmatic children. Nitric Oxide 2011; 25:288-93. [PMID: 21621632 DOI: 10.1016/j.niox.2011.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Revised: 05/12/2011] [Accepted: 05/16/2011] [Indexed: 01/12/2023]
Abstract
BACKGROUND The aim of our study was to assess risk factors of increased FeNO in asthmatic children with no cat at home. METHODS It was a retrospective, cross-sectional study. We evaluated data from medical documentation of children with asthma: FeNO results, allergen sensitization, seasonal allergen exposure, FEV(1), allergic rhinitis (AR) diagnosis and cat presence at home. We assessed asthma severity using mean doses of inhaled glucocorticosteroids and a management approach based on control according to the newest guidelines of Global Initiative for Asthma (GINA) throughout the last three months before the measurement of FeNO and spirometry. RESULTS 316 patients (age 6-18) completed the study. Sensitization to cat dander was associated with the highest median value of FeNO concentration compared to other allergens in our patients (28,4ppb) and co-existing sensitization did not affect FeNO level. Median levels of FeNO increased linearly with patient's age. In asthmatics with AR, the levels of FeNO were increased significantly compared to asthmatics without AR (20.8 vs. 16.3, respectively). We showed that in patients without AR, sensitization to cat allergen was associated with more severe asthma in comparison to other perennial allergy (step 4 vs. other steps according to GINA treatment steps). The above relation was not observed in patients with AR. We did not observe correlation between allergy profile and FEV(1) among patients in neither subgroup nor in general population. CONCLUSIONS We revealed that sensitization to cat dander was associated with the highest increase of FeNO concentration compared to other allergens in patients not having any cat at home ever. We also observed that in patients without allergic rhinitis, sensitization to cat allergen, compared to other perennial allergy, was associated with more severe asthma.
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Affiliation(s)
- Tomasz Grzelewski
- Department of Pediatrics and Allergy, Medical University of Lodz, N. Copernicus Hospital, Lodz, Poland
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Exhaled nitric oxide and urinary EPX levels in infants: a pilot study. Clin Mol Allergy 2011; 9:8. [PMID: 21575173 PMCID: PMC3117812 DOI: 10.1186/1476-7961-9-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 05/16/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Objective markers of early airway inflammation in infants are not established but are of great interest in a scientific setting. Exhaled nitric oxide (FeNO) and urinary eosinophilic protein X (uEPX) are a two such interesting markers. OBJECTIVE To investigate the feasibility of measuring FeNO and uEPX in infants and their mothers and to determine if any relations between these two variables and environmental factors can be seen in a small sample size. This was conducted as a pilot study for the ongoing Swedish Environmental Longitudinal Mother and child Asthma and allergy study (SELMA). METHODS Consecutive infants between two and six months old and their mothers at children's health care centres were invited, and 110 mother-infant pairs participated. FeNO and uEPX were analysed in both mothers and infants. FeNO was analyzed in the mothers online by the use of the handheld Niox Mino device and in the infants offline from exhaled air sampled during tidal breathing. A 33-question multiple-choice questionnaire that dealt with symptoms of allergic disease, heredity, and housing characteristics was used. RESULTS FeNO levels were reduced in infants with a history of upper respiratory symptoms during the previous two weeks (p < 0.002). There was a trend towards higher FeNO levels in infants with windowpane condensation in the home (p < 0.05). There was no association between uEPX in the infants and the other studied variables. CONCLUSION The use of uEPX as a marker of early inflammation was not supported. FeNO levels in infants were associated to windowpane condensation. Measuring FeNO by the present method may be an interesting way of evaluating early airway inflammation. In a major population study, however, the method is difficult to use, for practical reasons.
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Janson C, Kalm-Stephens P, Foucard T, Alving K, Nordvall SL. Risk factors associated with allergic and non-allergic asthma in adolescents. CLINICAL RESPIRATORY JOURNAL 2010; 1:16-22. [PMID: 20298273 DOI: 10.1111/j.1752-699x.2007.00001.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Christer Janson
- Department of Medical Sciences: Respiratory Medicine and Allergology, Uppsala University, Uppsala, Sweden.
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Effects of the indoor environment on the fraction of exhaled nitric oxide in school-aged children. Can Respir J 2010; 16:e18-23. [PMID: 19557209 DOI: 10.1155/2009/954382] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The fractional concentration of exhaled nitric oxide (FeNO) appears to be a good marker for airway inflammation in children with asthma. OBJECTIVE To evaluate the effect of environmental exposures on exhaled nitric oxide in a community sample of children. METHODS The relationship among exhaled nitric oxide, underlying disease and home environmental exposures was examined using questionnaire data and measurement of exhaled nitric oxide in a cross-sectional study of 1135 children that included healthy children, and children with allergies and/or asthma who were attending grades 4 through 6 in Windsor, Ontario. RESULTS Among healthy children, there was a positive association between FeNO and occupancy (P<0.02). Compared with forced air and hot water radiant heat, electric baseboard heating was associated with a significant increase of FeNO in healthy children (P=0.007) and children with allergies (P=0.043). FeNO was not associated with environmental tobacco smoke exposure or reported surface mold. The presence of pet dog(s), but not cats, was associated with a significantly lower FeNO in healthy children (P<0.001) and in children with reported allergies (P<0.001). CONCLUSIONS The type of heating system, but not previously reported environmental tobacco smoke or mold exposure appears to affect exhaled nitric oxide in children. Exposure to different types of pets may have disparate effects on airway inflammation.
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Syk J, Undén AL, Alving K. Relationship between exhaled nitric oxide and IgE sensitisation in patients with asthma: influence of steroid treatment. CLINICAL RESPIRATORY JOURNAL 2010; 3:143-51. [PMID: 20298397 DOI: 10.1111/j.1752-699x.2008.00124.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The influence of the degree of immunoglobulin E (IgE) sensitisation on the fraction of expired nitric oxide (FE(NO)) in asthma patients being treated with inhaled corticosteroids (ICS) is not well known. OBJECTIVES To investigate the relationship between IgE sensitisation and FE(NO), and the effect of a step-up in ICS treatment on this relationship, in patients with allergic asthma. METHODS A primary health care centre recruited 20 non-smoking patients with perennial allergic asthma (18 years-50 years, six male) outside the pollen season. At every visit (0, 2, 4, 8 weeks), FE(NO) was measured and an exposure questionnaire was completed. ICS dose was adjusted according to FE(NO) (>or=22 ppb prescribed increase in ICS). Quantitative analyses of serum IgE (eight common aeroallergens) confirmed allergy. RESULTS At baseline, FE(NO) and the sum of IgE antibody titres for perennial allergens correlated significantly (r = 0.47, P = 0.04). After a step-up in ICS treatment, this correlation had disappeared. Nine patients had persistently elevated FE(NO) at last visit (mean 35 ppb vs 16 ppb). This group was more frequently exposed to relevant allergens or colds (89% vs 27% of patients, P < 0.05) and had higher IgE antibody titres (perennial allergens) compared with the normalised group (mean 28.9 kU/L vs 10.7 kU/L, P < 0.05). CONCLUSION Serum IgE against perennial allergens and FE(NO) correlate in patients with allergic asthma. However, this relationship disappears after a high-dose ICS regimen, suggesting that FE(NO) relates to bronchial inflammation and not IgE levels per se. High degree of IgE sensitisation together with allergen exposure may lead to ICS-resistant airways inflammation.
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Affiliation(s)
- Jörgen Syk
- Department of Neurobiology, Caring Sciences and Society, Karolinska Institutet, Stockholm, Sweden.
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Kovesi T, Dales R. Exhaled nitric oxide and respiratory symptoms in a community sample of school aged children. Pediatr Pulmonol 2008; 43:1198-205. [PMID: 19003883 DOI: 10.1002/ppul.20927] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To test the association between reported allergy and allergic diseases, respiratory symptoms, and the fractional concentration of exhaled nitric oxide (FeNO), in a community sample of school aged children. METHODOLOGY We administered a respiratory questionnaire and measured FeNO in a cross-sectional study of 1,135 children. RESULTS FeNO was significantly greater in children with reported asthma (20.3 (standard deviation (SD) 21.3) parts per billion (ppb)) or allergies (18.1 (SD 18.0) ppb) than in healthy children (14.0 (SD 13.4) ppb). It was greater in children with asthma and reported allergies (22.8 (SD 23.6) ppb), than in children with asthma but no allergies (15.8 (SD 15.6) ppb) (overall P-value between disease groups = 0.002). FeNO was not related to respiratory symptoms in healthy children. Eczema was associated with an elevated FeNO concentration, even in the absence of respiratory symptoms. Some children with reported allergies but not asthma who had respiratory symptoms suggestive of asthma had elevated FeNO concentrations, and the proportion of healthy children with reported bronchitis or pneumonia in the past year who had an abnormally high FeNO concentration was significantly elevated. CONCLUSIONS In a community sample of children, FeNO concentrations appear to reflect allergic conditions, including allergic asthma, reported allergies, and eczema, rather than just asthma, particularly since asthma in children may be non-allergic. FeNO is similarly elevated in school aged children with reported asthma or reported allergies. FeNO is higher in children with asthma and allergies than in children with asthma alone. However, an elevated FeNO may help alert the clinician to the possibility of undiagnosed asthma.
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Affiliation(s)
- Tom Kovesi
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada.
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Cibella F, Cuttitta G, La Grutta S, Passalacqua G, Viegi G. Factors that influence exhaled nitric oxide in Italian schoolchildren. Ann Allergy Asthma Immunol 2008; 101:407-12. [PMID: 18939730 DOI: 10.1016/s1081-1206(10)60318-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Conflicting results exist about the meaning of exhaled nitric oxide (eNO) in epidemiologic studies, mainly because of the numerous factors that may affect the measurement. OBJECTIVES To evaluate the role of the factors that influence eNO levels in a sample of schoolchildren with or without respiratory diseases. We studied 335 schoolchildren, ages 10 to 16 years, from 8 schools in Palermo, Italy. After a respiratory questionnaire was completed, spirometry, skin tests, and eNO measurements were performed. RESULTS Among 335 children, 13.7% reported symptoms of bronchial asthma, 46.9% reported symptoms of rhinitis, and 39.4% were asymptomatic. The ratio of forced expiratory volume in 1 second to forced vital capacity was 87.6% (SD, 6.4%) in the bronchial asthma group, 90.6% (SD, 5.0%) in the rhinitis group, and 90.4% (SD, 5.1%) in the asymptomatic group (P < .002). Atopic children constituted 52.2% of the bronchial asthma group, 40.1% of the rhinitis group, and 28.8% of the asymptomatic group. Among atopic children, 102 (82%) had a positive skin test result for Dermatophagoides. Median eNO was 12.6 ppb in nonatopic children and 21.2 ppb in atopic children (P < .001, by Mann-Whitney U test). Among asymptomatic children, atopic children had significantly higher eNO levels than did nonatopic children (P < .001). In nonatopic children, no difference was found in log transformation eNO among healthy, rhinitic, or asthmatic children. Log transformation eNO increased with the number of positive skin test results (P < .001). Atopy, asthma, male sex, and indoor allergens were predictors of increased eNO in a logistic model. CONCLUSIONS Atopy (in particular, sensitization to indoor and perennial allergens) is strongly associated with higher eNO levels. Such association is enhanced by asthma.
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Affiliation(s)
- Fabio Cibella
- Consiglio Nazionale delle Ricerche, Istituto di Biomedicina e Immunologia Molecolare, Palermo, Italy.
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Piacentini GL, Peroni DG, Bodini A, Boner AL. Exhaled nitric oxide in children with asthma at high altitude. J Allergy Clin Immunol 2007; 120:1226-7; author reply 1227-8. [PMID: 17716722 DOI: 10.1016/j.jaci.2007.06.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2007] [Accepted: 06/21/2007] [Indexed: 11/22/2022]
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Malinovschi A, Janson C, Holmkvist T, Norbäck D, Meriläinen P, Högman M. IgE sensitisation in relation to flow-independent nitric oxide exchange parameters. Respir Res 2006; 7:92. [PMID: 16787532 PMCID: PMC1553446 DOI: 10.1186/1465-9921-7-92] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2006] [Accepted: 06/20/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A positive association between IgE sensitisation and exhaled NO levels has been found in several studies, but there are no reports on the compartment of the lung that is responsible for the increase in exhaled NO levels seen in IgE-sensitised subjects. METHODS The present study comprised 288 adult subjects from the European Community Respiratory Health Survey II who were investigated in terms of lung function, IgE sensitisation (sum of specific IgE), smoking history and presence of rhinitis and asthma. Mean airway tissue concentration of NO (CawNO), airway transfer factor for NO (DawNO), mean alveolar concentration of NO (CalvNO) and fractional exhaled concentration of NO at a flow rate of 50 mL s(-1) (FENO 0.05) were determined using the extended NO analysis. RESULTS IgE-sensitised subjects had higher levels (geometric mean) of FENO 0.05 (24.9 vs. 17.3 ppb) (p < 0.001), DawNO (10.5 vs. 8 mL s(-1)) (p = 0.02) and CawNO (124 vs. 107 ppb) (p < 0.001) and positive correlations were found between the sum of specific IgE and FENO 0.05, CawNO and DawNO levels (p < 0.001 for all correlations). Sensitisation to cat allergen was the major determinant of exhaled NO when adjusting for type of sensitisation. Rhinitis and asthma were not associated with the increase in exhaled NO variables after adjusting for the degree of IgE sensitisation. CONCLUSION The presence of IgE sensitisation and the degree of allergic sensitisation were related to the increase in airway NO transfer factor and the increase in NO concentration in the airway wall. Sensitisation to cat allergen was related to the highest increases in exhaled NO parameters. Our data suggest that exhaled NO is more a specific marker of allergic inflammation than a marker of asthma or rhinitis.
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Affiliation(s)
- Andrei Malinovschi
- Department of Medical Cell Biology: Integrative Physiology, Uppsala University, Uppsala, Sweden
| | - Christer Janson
- Asthma and Allergy Research Centre, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences: Respiratory Medicine and Allergology, Uppsala University, Uppsala, Sweden
| | - Thomas Holmkvist
- Department of Medical Cell Biology: Integrative Physiology, Uppsala University, Uppsala, Sweden
| | - Dan Norbäck
- Asthma and Allergy Research Centre, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences: Occupational and Environmental Medicine, Uppsala University, Uppsala, Sweden
| | - Pekka Meriläinen
- Department of Engineering Physics and Mathematics, Helsinki University of Technology, Helsinki, Finland
| | - Marieann Högman
- Department of Medical Cell Biology: Integrative Physiology, Uppsala University, Uppsala, Sweden
- Asthma and Allergy Research Centre, Uppsala University, Uppsala, Sweden
- Department of Caring Sciences and Sociology; Section of Medical Science, University of Gävle, Gävle, Sweden
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