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Ridolo E, Incorvaia C, Martignago I, Caminati M, Canonica GW, Senna G. Sex in Respiratory and Skin Allergies. Clin Rev Allergy Immunol 2019; 56:322-332. [PMID: 29306980 DOI: 10.1007/s12016-017-8661-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
A bulk of literature demonstrated that respiratory allergy, and especially asthma, is prevalent in males during childhood, while it becomes more frequent in females from adolescence, i.e., after menarche, to adulthood. The mechanisms underlying the difference between females and males are the effects on the immune response of female hormones and in particular the modulation of inflammatory response by estrogens, as well as the result of the activity of various cells, such as dendritic cells, innate lymphoid cells, Th1, Th2, T regulatory (Treg) and B regulatory (Bregs) cells, and a number of proteins and cytokines, which include interleukin (IL)-4, IL-5, IL-10, and IL-13. As far as sexual dimorphism is concerned, a gender difference in the expression profiles of histamine receptors and of mast cells was demonstrated in experimental studies. A critical phase of hormone production is the menstrual cycle, which often is associated with asthma deterioration, as assessed by worsening of clinical symptoms and increase of bronchial hyperresponsiveness. In asthmatic woman, there is a high risk to develop more severe asthma during menstruation. The higher prevalence of asthma in females is confirmed also in the post-menopause age, but the underlying mechanisms are not yet understood. In pregnancy, asthma may worsen but may also improve or remain unchanged, with no significant difference in frequency of these three outcomes. For allergic rhinitis, the available studies indicate, likewise asthma, a male predominance in prevalence in childhood that shifts to a female predominance in adolescence and adulthood, but further investigation is needed.
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Affiliation(s)
- Erminia Ridolo
- Medicine and Surgery Department, University of Parma, Parma, Italy
| | | | - Irene Martignago
- Medicine and Surgery Department, University of Parma, Parma, Italy
| | - Marco Caminati
- Asthma Center and Allergy Unit, Verona University Hospital, P.le L.A. Scuro 10, 37134, Verona, Italy.
| | - Giorgio Walter Canonica
- Personalized Medicine Asthma & Allergy Clinic, Humanitas University, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Gianenrico Senna
- Asthma Center and Allergy Unit, Verona University Hospital, P.le L.A. Scuro 10, 37134, Verona, Italy
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Alves CC, Arruda LKP, Oliveira FR, Massaro JD, Aquino BJ, Paz MA, Castelli EC, Mendes-Junior CT, Donadi EA. Human leukocyte antigen-G 3' untranslated region polymorphisms are associated with asthma severity. Mol Immunol 2018; 101:500-506. [PMID: 30142579 DOI: 10.1016/j.molimm.2018.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 08/06/2018] [Accepted: 08/12/2018] [Indexed: 01/03/2023]
Abstract
Asthma is a genetically complex chronic inflammatory airway disorder, and according to disease pathogenesis, clinical manifestations may vary according to asthma severity. A gene region close to the human leukocyte antigen-G (HLA-G) gene was identified as an independent susceptibility marker for asthma. Considering that the HLA-G immune checkpoint molecule may modulate inflammation, we evaluated the diversity of the HLA-G 3' untranslated region (3'UTR) in asthmatic patients stratified according to disease severity. We evaluate the entire HLA-G 3'UTR segment in 115 Brazilian patients stratified into mild (n=29), moderate (n=21) and severe asthmatics (n=65), and in 116 healthy individuals. HLA-G 3'UTR typing was performed using Sanger sequencing. The multiple comparisons among patients stratified according to disease severity revealed several associations; however, after Bonferroni's correction, the following results remained significant: i) the +3010C and +3142G alleles were overrepresented in mild asthma patients when compared to controls; ii) the +3010G and +3142C alleles were overrepresented in severe asthma patients in comparison to patients with mild asthma. In conclusion, the +3010C/G and +3142C/G HLA-G 3'UTR variation sites were differentially associated according to asthma severity.
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Affiliation(s)
- Cinthia C Alves
- Department of Biochemistry and Immunology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.
| | - Luísa K P Arruda
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Fabíola R Oliveira
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Juliana D Massaro
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Beatriz J Aquino
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Michelle A Paz
- São Paulo State University (UNESP), School of Medicine, Molecular Genetics and Bioinformatics Laboratory, Botucatu, SP, Brazil
| | - Erick C Castelli
- São Paulo State University (UNESP), School of Medicine, Molecular Genetics and Bioinformatics Laboratory, Botucatu, SP, Brazil; São Paulo State University (UNESP), School of Medicine, Department of Pathology, Botucatu, SP, Brazil
| | - Celso T Mendes-Junior
- Departamento de Química, Laboratório de Pesquisas Forenses e Genômicas, Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Eduardo A Donadi
- Department of Biochemistry and Immunology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil; Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
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Severe Asthma Phenotypes - How Should They Guide Evaluation and Treatment? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 5:901-908. [PMID: 28689840 DOI: 10.1016/j.jaip.2017.05.015] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 05/15/2017] [Accepted: 05/17/2017] [Indexed: 11/22/2022]
Abstract
Although patients with "severe" asthma tend to be characterized by ongoing symptoms and airway inflammation despite treatment with high doses of inhaled and systemic corticosteroids, there is increasing recognition of marked phenotypic heterogeneity within affected patients. Although "precision medicine" approaches for patients with severe asthma are needed, there are many hurdles that must be overcome in daily practice. The National Heart, Lung and Blood Institute's Severe Asthma Research Program (SARP) has been at the forefront of phenotype discovery in severe asthma for the past decade. SARP, along with other international groups, has described clinical severe asthma phenotypes in both adults and children that can be evaluated in the clinical setting. Although these clinical phenotypes provide a good "starting point" for addressing disease heterogeneity in severe asthma in everyday practice, more efforts are needed to understand how these phenotypes relate to underlying disease mechanisms and pharmacological treatment responses. This review highlights the clinical asthma phenotypes identified to date, their associations with underlying endotypes and potential biomarkers, and remaining knowledge gaps that must be addressed before precision medicine can become a reality for patients with severe asthma.
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Alexandrova E, Nassa G, Corleone G, Buzdin A, Aliper AM, Terekhanova N, Shepelin D, Zhavoronkov A, Tamm M, Milanesi L, Miglino N, Weisz A, Borger P. Large-scale profiling of signalling pathways reveals an asthma specific signature in bronchial smooth muscle cells. Oncotarget 2018; 7:25150-61. [PMID: 26863634 PMCID: PMC5039037 DOI: 10.18632/oncotarget.7209] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 01/26/2016] [Indexed: 02/06/2023] Open
Abstract
Background Bronchial smooth muscle (BSM) cells from asthmatic patients maintain in vitro a distinct hyper-reactive (“primed”) phenotype, characterized by increased release of pro-inflammatory factors and mediators, as well as hyperplasia and/or hypertrophy. This “primed” phenotype helps to understand pathogenesis of asthma, as changes in BSM function are essential for manifestation of allergic and inflammatory responses and airway wall remodelling. Objective To identify signalling pathways in cultured primary BSMs of asthma patients and non-asthmatic subjects by genome wide profiling of differentially expressed mRNAs and activated intracellular signalling pathways (ISPs). Methods Transcriptome profiling by cap-analysis-of-gene-expression (CAGE), which permits selection of preferentially capped mRNAs most likely to be translated into proteins, was performed in human BSM cells from asthmatic (n=8) and non-asthmatic (n=6) subjects and OncoFinder tool were then exploited for identification of ISP deregulations. Results CAGE revealed >600 RNAs differentially expressed in asthma vs control cells (p≤0.005), with asthma samples showing a high degree of similarity among them. Comprehensive ISP activation analysis revealed that among 269 pathways analysed, 145 (p<0.05) or 103 (p<0.01) are differentially active in asthma, with profiles that clearly characterize BSM cells of asthmatic individuals. Notably, we identified 7 clusters of coherently acting pathways functionally related to the disease, with ISPs down-regulated in asthma mostly targeting cell death-promoting pathways and up-regulated ones affecting cell growth and proliferation, inflammatory response, control of smooth muscle contraction and hypoxia-related signalization. Conclusions These first-time results can now be exploited toward development of novel therapeutic strategies targeting ISP signatures linked to asthma pathophysiology.
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Affiliation(s)
- Elena Alexandrova
- Laboratory of Molecular Medicine and Genomics, Department of Medicine and Surgery, University of Salerno, Baronissi (SA), Italy.,Genomix4Life Srl, Campus of Medicine, University of Salerno, Baronissi (SA), Italy
| | - Giovanni Nassa
- Laboratory of Molecular Medicine and Genomics, Department of Medicine and Surgery, University of Salerno, Baronissi (SA), Italy
| | - Giacomo Corleone
- Laboratory of Molecular Medicine and Genomics, Department of Medicine and Surgery, University of Salerno, Baronissi (SA), Italy
| | - Anton Buzdin
- Laboratory of Bioinformatics, D. Rogachyov Federal Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia.,Pathway Pharmaceuticals, Wan Chai, Hong Kong, Hong Kong SAR
| | - Alexander M Aliper
- Laboratory of Bioinformatics, D. Rogachyov Federal Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia.,Pathway Pharmaceuticals, Wan Chai, Hong Kong, Hong Kong SAR
| | | | - Denis Shepelin
- Pathway Pharmaceuticals, Wan Chai, Hong Kong, Hong Kong SAR.,Group for Genomic Regulation of Cell Signalling Systems, Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Moscow, Russia
| | | | - Michael Tamm
- Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Luciano Milanesi
- Institute of Biomedical Technologies, National Research Council, Segregate (MI), Italy
| | - Nicola Miglino
- Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Alessandro Weisz
- Laboratory of Molecular Medicine and Genomics, Department of Medicine and Surgery, University of Salerno, Baronissi (SA), Italy.,Molecular Pathology and Medical Genomics Unit, 'SS. Giovanni di Dio e Ruggi d'Aragona - Schola Medica Salernitana' University Hospital, Salerno (SA), Italy
| | - Pieter Borger
- Department of Biomedicine, University Hospital Basel, Basel, Switzerland
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Abstract
Inhaled corticosteroids are the mainstay of asthma treatment using a step-up approach with incremental dosing and additional controller medications in order to achieve symptom control and prevent exacerbations. While most patients respond well to this treatment approach, some patients remain refractory despite high doses of inhaled corticosteroids and a long-acting β-agonist. The problem lies in the heterogeneity of severe asthma, which is further supported by the emergence of severe asthma phenotypes. This heterogeneity contributes to the variability in treatment response. Randomized controlled trials involving add-on therapies in poorly controlled asthma have challenged the idea of a "one size fits all" approach targeting specific phenotypes in their subject selection. This review discusses severe asthma phenotypes from unbiased clustering approaches and the most recent scientific evidence on novel treatments to provide a guide in personalizing severe asthma treatment.
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Affiliation(s)
- Maria Theresa D Opina
- Department of Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Wendy C Moore
- Department of Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
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Mäkikyrö EMS, Jaakkola MS, Jaakkola JJK. Subtypes of asthma based on asthma control and severity: a latent class analysis. Respir Res 2017; 18:24. [PMID: 28114991 PMCID: PMC5259948 DOI: 10.1186/s12931-017-0508-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 01/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Asthma subtyping is a complex new field of study. Usually both etiological and outcome factors of asthma have been used simultaneously for subtyping thus making the interpretation of the results difficult. Identification of subtypes of asthma based on questionnaire data only will be useful for both treatment of asthma and for research. Our objective was to identify asthma subtypes that capture both asthma control and severity based on easily accessible variables. METHODS We applied latent class analysis for the 1995 adult asthmatics, 692 men and 1303 women, of the Northern Finnish Asthma Study (NoFAS). The classifying variables included use of asthma medication within the last 12 months, St. George's Respiratory Questionnaire score, and asthma-related healthcare use within the last 12 months. Covariates adjusted for included COPD, allergic rhinitis/allergic eczema, BMI, age and sex. All information was based on self-administered questionnaires. RESULTS We identified four subtypes for women: Controlled, mild asthma (41% of participants); Partly controlled, moderate asthma (24%); Uncontrolled asthma, unknown severity (26%), and Uncontrolled, severe asthma (9%). For men we identified three subtypes: Controlled, mild asthma (31%); Poorly controlled asthma, unknown severity (53%); and Partly controlled, severe asthma (17%). For almost 96% of the subjects this subtyping was accurate. The covariates fitted in the model were based on clinical judgment and were good predictors of class membership. CONCLUSIONS Our results show that it is possible to form meaningful and accurate asthma subtypes based on questionnaire data, and that separate classification should be applied for men and women.
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Affiliation(s)
- Elina M S Mäkikyrö
- Center for Environmental and Respiratory Health Research (CERH), University of Oulu, PO Box 5000, FI-90014, Oulu, Finland.,Medical Research Center Oulu (MRC Oulu), Oulu, Finland
| | - Maritta S Jaakkola
- Center for Environmental and Respiratory Health Research (CERH), University of Oulu, PO Box 5000, FI-90014, Oulu, Finland.,Medical Research Center Oulu (MRC Oulu), Oulu, Finland
| | - Jouni J K Jaakkola
- Center for Environmental and Respiratory Health Research (CERH), University of Oulu, PO Box 5000, FI-90014, Oulu, Finland. .,Medical Research Center Oulu (MRC Oulu), Oulu, Finland.
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Carr TF, Bleecker E. Asthma heterogeneity and severity. World Allergy Organ J 2016; 9:41. [PMID: 27980705 PMCID: PMC5129643 DOI: 10.1186/s40413-016-0131-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 11/22/2016] [Indexed: 02/06/2023] Open
Abstract
Asthma is a common, chronic inflammatory airways disease characterized by a clinical syndrome of bronchial hyperresponsiveness, inflammation, and reversible airflow obstruction. Individuals with asthma can vary widely in clinical presentation, severity, and pathobiology. The incident factors, pathogenesis, prognosis, and treatment of asthma remain incompletely understood. Utilizing measurable characteristics of asthmatic patients, including demographic, physiologic, and biologic markers, can however identify meaningful phenotypic categories in asthma. Identification of these phenotypes may help improve precision therapeutics targeted toward an individual’s’ disease, and may identify strategies for preventing progression of disease severity.
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Affiliation(s)
- Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724-5030 USA
| | - Eugene Bleecker
- Center for Genomics and Personalized Medicine Research, Wake Forest School of Medicine, Winston-Salem, NC USA
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Fitzpatrick AM. Severe Asthma in Children: Lessons Learned and Future Directions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:11-9; quiz 20-1. [PMID: 26772923 DOI: 10.1016/j.jaip.2015.10.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 10/14/2015] [Accepted: 10/16/2015] [Indexed: 01/02/2023]
Abstract
Severe asthma in children is a complicated and heterogeneous disorder that is extremely challenging to treat. Although most children with asthma derive clinical benefit from daily administration of low-to-medium-dose inhaled corticosteroid (ICS) therapy, a small subset of children with "severe" or "refractory" asthma require high doses of ICS and even systemic corticosteroids to maintain symptom control. These children with severe asthma are at increased risk for adverse outcomes including medication-related side effects and recurrent and life-threatening exacerbations that significantly impair quality of life. This review highlights findings on severe asthma in school-age children (age 6-17 years) from the National Heart, Lung and Blood Institute's Severe Asthma Research Program (SARP) over a 10-year period, between 2001 and 2011. Although SARP has advanced knowledge of the unique clinical, biological, and molecular attributes of severe asthma in children, considerable gaps remain for which additional studies are needed.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta Center for Cystic Fibrosis and Airways Disease Research, Atlanta, Ga.
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Wu MK, Wang HY, Chen YW, Lin PY, Wu CK, Tseng PT. Significantly Higher Prevalence Rate of Asthma and Bipolar Disorder Co-Morbidity: A Meta-Analysis and Review Under PRISMA Guidelines. Medicine (Baltimore) 2016; 95:e3217. [PMID: 27043688 PMCID: PMC4998549 DOI: 10.1097/md.0000000000003217] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Asthma and bipolar disorder (BD) are 2 distinct diseases that share similar pathophysiology. This study aimed to determine their relationship thorough a meta-analysis of articles on their comorbidity rate. The aim of the study is to examine the overall prevalence rate of BD in asthmatic patients and of asthma in BD patients compared to healthy controls. Electronic research of PubMed and ClinicalTrials.gov was performed. Articles discussing the prevalence rate of BD in patients with/without asthma and the prevalence rate of asthma in those with/without BD, as well as clinical trials in humans and case-controlled trials or cohort studies, were all included. Case reports or series and nonclinical trials were excluded. Through a random-effects model, a meta-analysis of the results of 4 studies comparing the prevalence rate of BD in patients with/without asthma, and in 6 studies comparing the prevalence rate of asthma in subjects with/without BD were performed. There were significantly higher prevalence rates of BD in asthmatic patients than in healthy controls (P < 0.001) and of asthma in BD patients than in healthy controls (P < 0.001). Only the patient's mean age significantly modulated the odds ratio of the prevalence rate of asthma in BD patients (slope = 0.015, P < 0.001). Only 10 studies were included and most were cross-sectional studies. The possible confounding effect of medication on BD or asthma onset was not investigated. Any possible etiology of the comorbidity was also not determined. This meta-analysis highlights the importance of the significantly high comorbid rate of BD and asthma, and the positive association with age. Special attention must be given to the comorbidity of asthma and BD, especially in older patients.
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Affiliation(s)
- Ming-Kung Wu
- From the Department of Psychiatry (MKW, P-YL), Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine; Center for Translational Research in Biomedical Sciences (M-KW, P-YL), Kaohsiung Chang Gung Memorial Hospital, Kaohsiung; Department of Psychiatry (H-YW, C-KW, P-TT), Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai's Home; and Department of Neurology (Y-WC), E-Da Hospital, Kaohsiung, Taiwan
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Sharifi H, Ghanei M, Sadr M, Emami H, Fakharian A, Hessami Z, Aryanpur M, Jamaati H, Masjedi MR. Prevalence and Geographic Distribution Pattern of Asthma in Tehran by ECRHS. TANAFFOS 2016; 15:236-242. [PMID: 28469680 PMCID: PMC5410120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Asthma, involving 5-10% of global population, has a heterogeneous distribution in the community regardless of age and its prevalence and incidence tend to grow worldwide as reported by many recent epidemiologic surveys. MATERIALS AND METHODS The present study aimed to survey the prevalence of asthma symptoms in Tehran as the first attempt in terms of situation analysis of the disease in the Iranian society by using relevant parts of the European Community Respiratory Health Survey (ECRHS) questionnaire. RESULTS Wheezing was reported in 48% of males and 34% of females in the age range of 20-44 years, around 50% of which was associated with breathlessness or cold., the people who answered "yes" to the questions 1 (wheezing), 4 (coughing), 5 (asthma history) or 7 (nasal allergy) were totally 211 among whom 124 (58.8%) were males and the rest (41.2%) were females. CONCLUSION Asthma symptoms decrease the quality of life and impose high costs on the healthcare system in many countries. A low rate of participants had been informed about their asthma by physicians and not all of them were taking medications. Risk factor analysis and control is strongly advised in order to lessen the prevalence of the disease and symptoms. Air pollution, smoking, unhealthy life style and many personal and social factors need to be assessed and eliminated. It seems that a- second phase- ECRH survey should be conducted to assess the situation of asthma through population of Tehran.
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Affiliation(s)
- Hooman Sharifi
- Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mostafa Ghanei
- Baqiyatallah Research Center of Gastroentrology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Makan Sadr
- Tracheal Diseases Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Correspondence to: Sadr M Address: Tracheal Diseases Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Email address:
| | - Habib Emami
- Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Atefeh Fakharian
- Chronic Respiratory Diseases Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Hessami
- Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahshid Aryanpur
- Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamidreza Jamaati
- Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
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