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

Allergic sensitisation and type-2 inflammation is associated with new-onset and persistent allergic disease

BACKGROUND

Allergic disease is common. The aim of this study was to look at the change in asthma and rhinitis over time and to characterise factors contributing to remission and persistence of disease.

METHODS

This cohort study included 255 individuals with or without asthma and or rhinitis that participated in a population survey and a follow-up 10 years later. The participants were tested for allergic sensitisation, total IgE, multiplex allergen component analysis and type-2 inflammatory markers: exhaled nitric oxide (F_E NO), eosinophil cationic protein (ECP) and eosinophil-derived neurotoxin (EDN).

RESULTS

Of the 132 healthy individuals, 112 remained healthy, 16 developed rhinitis, 4 asthma and rhinitis over the 10 years. Out of 82 subjects with rhinitis, 26 went into remission, 53 remained unchanged and 3 developed asthma in addition to rhinitis. None of the 41 participants with asthma and rhinitis went into remission. Subjects with persistent rhinitis and asthma had higher levels of total IgE (odds ratio [OR] 95% confidence interval [CI]: 6.16 [3.05-12.5]) at baseline and after 10 years, and F_E NO and ECP at baseline (OR per log unit increase, 95% CI 5.21 [1.20-22.7] and 6.32 [1.52-26.4], respectively), compared with those that remained healthy. Subjects with persistent rhinitis were more likely to be sensitised to grass pollen and had higher total IgE levels than those that went into remission. Individuals with persistent asthma were more likely to be sensitised to tree pollen and furry animals than those with only persistent rhinitis (OR 95% CI: 3.50 [1.29-9.49] and 6.73 [2.00-22.6], respectively).

CONCLUSION

IgE sensitisation and total IgE levels are associated with the persistence of rhinitis and asthma. Participants with persistent allergic disease had higher levels of allergen sensitisation and type 2 inflammation markers at baseline than those who remained healthy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Interaction of smoking and social status on the risk of respiratory outcomes in a Swedish adult population: A Nordic Epilung study

BACKGROUND

Evidence abounds on the independent roles of social class and smoking in relation to obstructive airway diseases, but data are sparse on the impact of their interaction. We evaluated whether and to what extent social class and smoking interact in relation to risk of respiratory diseases in adults.

METHODS

Data from the population-based studies, West Sweden Asthma Study (WSAS, n = 23,753) and Obstructive Lung Disease in Northern Sweden studies (OLIN, n = 6519), were used, constituting randomly selected adults aged 20-75 years. Bayesian network analysis was used to estimate the probability for the interaction between smoking and socioeconomic status in relation to respiratory outcomes.

RESULTS

Occupational and educational SES modified the association between smoking and the probability of allergic and non-allergic asthma. Former smokers who were at intermediate non manual employees and manual workers in service had higher probability of allergic asthma compared to professionals and executives. Furthermore, former smokers with primary education had higher probability of non-allergic asthma than those with secondary and tertiary education. Similarly, former smokers among professionals and executives had higher probability of non-allergic asthma than manual and home workers and primary educated. Likewise, allergic asthma due to former smoking was higher among highly educated compared to low educated.

CONCLUSIONS

Beyond their independent roles, socioeconomic status and smoking interact in defining the risk of respiratory diseases. Clearer understanding of this interaction can help to identify population subgroups at most need of public health interventions.

Real-world study: drug reduction in children with allergic rhinitis and asthma receiving immunotherapy

Background: The reduction of pharmacological treatment after allergen immunotherapy (AIT) for house dust mites (HDMs) has been little studied in children. Objective: To evaluate the reduction of pharmacological treatment comparing children that receive HDM immunotherapy (AIT group) versus only pharmacotherapy. Methods: A historic cohort of children with rhinitis or asthma was assessed. The main outcome was the frequency of complete drug discontinuation. Results: 100% drug reduction was higher for rhinitis (4-year cumulative incidence: 30 vs 10.7%) and asthma (24.1 vs 10.5%) in the AIT group (n = 987) than in the pharmacotherapy group (n = 2012). Conclusion: Immunotherapy is associated with a significant reduction of pharmacotherapy in children. This is a marker of clinical control and could be associated with positive economic impact.

Transcriptomic analysis of asthma and allergic rhinitis reveals CST1 as a biomarker of unified airways

Background

Allergic rhinitis (AR) is an important risk factor for the development of asthma. The "unified airway" theory considers the upper and lower airways as a morphological and functional whole. However, studies exploring biomarkers linking the upper and lower airways in allergic disease are lacking, which may provide insight into the mechanisms underlying AR comorbid asthma.

Purpose

To integrate bioinformatics techniques to explore biomarkers in airway allergic diseases, and to provide a molecular etiology profile for preventing the development of asthma in AR patients.

Methods

Biomarkers were screened by identifying key genes common between AR and asthma through WGCNA and differential gene analysis. GO and KEGG analyses were performed using DAVID. Immuno-infiltration analysis was performed by CIBERSORTx. The predictive value of CST1 to distinguish Th2-high asthma was determined by ROC curves. GSEA was used to analyze the signaling pathways involved in CST1. TargetScan and miRNet were combined with GSE142237 to construct ceRNA network. CMap was used to explore potential therapeutic drugs.

Results

Validation of datasets showed that CST1 was the only gene that was up-regulated in both upper and lower airways in patients with AR and asthma, and correlation heatmaps showed that CST1 was the gene with the highest sum of correlation coefficients. GO and KEGG analysis demonstrated that the lower airways of AR patients were mainly involved in inflammatory and immune responses, similar to asthma. Immune infiltration showed that CST1 was mainly positively correlated with activated CD4 memory T cells. According to the ROC curve, CST1 showed excellent diagnostic efficiency for Th2-high asthma. GSEA indicated that CST1 was involved in the FcϵRI signaling pathway and O-glycan biosynthesis. A ceRNA network including the lncRNAs KCNQ1OT1 and NEAT1 was constructed. Four drugs, including verrucarin-A, had the potential to prevent the development of asthma in AR patients. In addition, corticosteroids were found to downregulate CST1 expression.

Conclusion

CST1 plays a key role in the development of AR comorbid asthma and may be a biomarker for airway allergic diseases. Targeted treatment of CST1 has the potential to prevent the development of asthma in AR patients and deserves further study.

Clinical Remission of Asthma and Allergic Rhinitis - in a Longitudinal Population Study

BACKGROUND

Although asthma and allergic rhinitis are chronic diseases, some patients experience periods of remission. Information on prognostic factors associated with the remission of asthma and allergic rhinitis is valuable in resource prioritization. This study investigated factors associated with the clinical remission of asthma and allergic rhinitis.

METHODS

In the Respiratory Health In Northern Europe (RHINE) study, data was collected with questionnaires in stage one (RHINE I, 1989-1992) and two follow-ups (RHINE II, 1999-2001 and RHINE III, 2010-2012) from Sweden, Norway, Denmark, Iceland and Estonia. Clinical remission was defined as having reported asthma or allergic rhinitis in RHINE I or RHINE II but not in RHINE III.

RESULTS

Of 13,052 participants, 975 (7.5%) reported asthma in RHINE I or RHINE II, and 3379 (25.9%) allergic rhinitis. Clinical remission of asthma and allergic rhinitis was found in 46.4% and 31.8%, respectively. Living in Estonia (OR (95% CI) 2.44 (1.22-4.85)) and living in an apartment (1.45 (1.06-1.98)) were related to remission of asthma, while subjects reporting allergic rhinitis (0.68 (0.51-0.90)), asthma onset ≤ 12 years of age (0.49 (0.35-0.68)), receiving treatment with antibiotics for respiratory illness (0.64 (0.47-0.87)) were less likely to have asthma remission. Factors related to a higher likelihood of remission of allergic rhinitis were no asthma at baseline, age ≥ 58 years in RHINE III, allergic rhinitis onset after 12 years of age, living in rural areas as a child, having only a primary school education and not being pregnant.

CONCLUSION

Clinical remission was found in almost one-half of those with asthma and one-third of persons with allergic rhinitis. Coexisting allergic symptoms were associated with less clinical asthma remission. Age, asthma symptoms and environmental factors in childhood, such as living in a rural area, were found to influence the clinical remission of allergic rhinitis.

Association between exposure to particulate matter and school absences in Korean asthmatic adolescents

Background

Because particulate matter (PM) and asthma are closely related, the prevalence of school absence among adolescents with asthma can be affected by the concentration of PM. We aimed to investigate the relationship between school absences due to asthma and the total number of days that the PM concentration exceeded the standard.

Methods

We used the data from the 16th Korea Youth Risk Behavior Survey and the PM levels of 17 metropolitan cities and provinces gathered from the AirKorea. Information on the characteristics of asthmatic adolescents and the prevalence of school absence was obtained using a questionnaire, while the PM levels based on the total number of days with poor and very poor PM grades were collected from the AirKorea website. Both χ² test and logistic regression analysis were performed using the weights presented in the original dataset.

Results

In the case of particulate matter of 10 microns in diameter or smaller (PM₁₀), the odds ratio (OR) after adjusting for confounders (sex, school year, body mass index, smoking history, diagnosis of allergic rhinitis, diagnosis of atopic dermatitis and city size) was 1.07 (95% confidence interval [CI]: 1.01–1.13) for absents due to asthma when the total days of poor and very poor grades of PM₁₀ (81 μg/m³ or higher) increased by 1 day. In the analysis of particulate matter of 2.5 microns in diameter or smaller (PM_2.5), the OR after adjusting for confounders was 1.01 (95% CI: 1.00–1.03) for absents due to asthma when the total number of days with poor and very poor PM_2.5 grades (36 μg/m³ or higher) increased by 1 day.

Conclusions

A significant association was observed between the total number of days of poor and very poor PM₁₀ and PM_2.5 grades and school absence due to asthma; PM can cause asthma exacerbation and affect the academic life.

The Impact of Tobacco Cigarettes, Vaping Products and Tobacco Heating Products on Oxidative Stress

Cells constantly produce oxidizing species because of their metabolic activity, which is counteracted by the continuous production of antioxidant species to maintain the homeostasis of the redox balance. A deviation from the metabolic steady state leads to a condition of oxidative stress. The source of oxidative species can be endogenous or exogenous. A major exogenous source of these species is tobacco smoking. Oxidative damage can be induced in cells by chemical species contained in smoke through the generation of pro-inflammatory compounds and the modulation of intracellular pro-inflammatory pathways, resulting in a pathological condition. Cessation of smoking reduces the morbidity and mortality associated with cigarette use. Next-generation products (NGPs), as alternatives to combustible cigarettes, such as electronic cigarettes (e-cig) and tobacco heating products (THPs), have been proposed as a harm reduction strategy to reduce the deleterious impacts of cigarette smoking. In this review, we examine the impact of tobacco smoke and MRPs on oxidative stress in different pathologies, including respiratory and cardiovascular diseases and tumors. The impact of tobacco cigarette smoke on oxidative stress signaling in human health is well established, whereas the safety profile of MRPs seems to be higher than tobacco cigarettes, but further, well-conceived, studies are needed to better understand the oxidative effects of these products with long-term exposure.

HSP70 upregulation in nasal mucosa of symptomatic children with allergic rhinitis and potential risk of asthma development

Allergic rhinitis and asthma are the most common causes of chronic inflammation of the upper and lower airways in childhood. However, a nasal biomarker that can link to pulmonary inflammation is yet to be found. The present paper aims to investigate the possible role in inflammation of two inducible 70-kDa Heat Shock Proteins (HSP70) members, HSPA1A/B and HSPA6, in nasal mucosa cells of allergic children through their mRNA expression analysis, and their correlation to both spirometric and FeNO values. The relationship between FeNO in lower airways and ∆Cts of HSPA1A/B in nasal mucosa seems to be influenced by clinical symptoms regardless of age, sex, and sensitization patterns. Therefore, HSP70 expression, as well as FeNO levels, could have a predictive capability to identify lower airways inflammation and thus to recognize rhinitic children having a potential risk of asthma development.

Comorbid allergic rhinitis and asthma: important clinical considerations

INTRODUCTION

The numerous links between allergic rhinitis and asthma have been extensively explored in the last two decades, gaining great concern within the scientific community. These two conditions frequently coexist in the same patient and share numerous pathogenetic and pathophysiological mechanisms.

AREAS COVERED

We reviewed major pathophysiological, epidemiological, and clinical links between allergic rhinitis and asthma. We also provided a comprehensive discussion of allergic rhinitis treatment according to current guidelines, with a particular focus on the relevance of allergic rhinitis therapies in patients with comorbid asthma.

EXPERT OPINION

We believe that there are several unmet needs for our patients, however, there are promising advances forecasted for the future. Although allergic rhinitis is a recognized risk factor for asthma, a proper asthma detection and prevention plan in allergic rhinitis patients is not available. Allergen immunotherapy (AIT) represents a promising preventive strategy and may deserve an earlier positioning in allergic rhinitis management. A multidisciplinary approach should characterize the journey of patients with respiratory allergies, with an adequate referral to specialized Allergy/Asthma centers. Molecular Allergy Diagnosis may provide support for optimal AIT use. Finally, a possible evolution of biological treatment can be envisaged, mainly if biosimilars decrease such therapies' costs.

Trained immunity in type 2 immune responses

Immunological memory of innate immune cells, also termed "trained immunity", allows for cross-protection against distinct pathogens, but may also drive chronic inflammation. Recent studies have shown that memory responses associated with type 2 immunity do not solely rely on adaptive immune cells, such as T- and B cells, but also involve the innate immune system and epithelial cells. Memory responses have been described for monocytes, macrophages and airway epithelial cells of asthmatic patients as well as for macrophages and group 2 innate lymphoid cells (ILC2) from allergen-sensitized or helminth-infected mice. The metabolic and epigenetic mechanisms that mediate allergen- or helminth-induced reprogramming of innate immune cells are only beginning to be uncovered. Trained immunity has been implicated in helminth-driven immune regulation and allergen-specific immunotherapy, suggesting its exploitation in future therapies. Here, we discuss recent advances and key remaining questions regarding the mechanisms and functions of trained type 2 immunity in infection and inflammation.

A study of Spirometric parameters in non asthmatic allergic rhinitis

Introduction

Allergic rhinitis (AR) is a common IgE -mediated inflammatory condition characterised by sneezing, nasal congestion, itching and rhinorrhoea. Nasal allergy is a strong risk factor for the onset of asthma in adults. Bronchial hyper-responsiveness (BHR) is a distinct feature of pathophysiology in asthma. Spirometric parameters like Forced Expiratory Volume in first second [FEV1] and Forced Expiratory Flow [FEF _25-75%] are known to be impaired in patients with allergic rhinitis. We studied these parameters in subjects of AR who have never experienced any chest symptoms. It is well known that, subjects with allergic rhinitis are at greater risk of developing overt bronchial asthma in future.

Methods

All patients presented with symptoms of allergic rhinitis without history of bronchial asthma were included. Patients those who were clinically diagnosed with allergic rhinitis were evaluated with absolute eosinophilic count, serum IgE and Spirometric assessment. In spirometry, post bronchodilator FEV1 reversibility and post bronchodilator FEF _25-75% values were used to assess lower airway abnormalities.

Results

Among 61 subjects, 32 were males and 29 were females. The maximum numbers [28] of patients were in 21-35 age group. Absolute eosinophil count was elevated in 38% of patients. 33% of patients showed elevated IgE values above 1000. 43% of patients showed FEV1 reversibility which is a sign of Bronchial hyperreactivity. 5% of patients showed impaired post bronchodilator FEF _25-75% which indicates presence of small airway disease. There was significant correlation between FEV1 reversibility and elevated IgE.

Conclusion

Impaired spirometric parameters indicate coexistence of bronchial impairment and hence predisposition to progression from allergic rhinitis alone to overt asthma in future. Thus careful evaluation of lower airway has to be done to rule out coexisting subclinical asthma.

Atopic Dermatitis: Disease Characteristics and Comorbidities in Smoking and Nonsmoking Patients from the TREATgermany Registry

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease with a multifactorial genesis including genetic predispositions and environmental risk and trigger factors. One of the latter possibly is smoking, indicated by an increased prevalence of AD in adults and children that are actively or passively exposed to cigarette smoke.

OBJECTIVES

In this study AD characteristics and its atopic comorbidities are compared in smoking and nonsmoking AD patients.

METHODS

TREATgermany is a non-interventional clinical registry which includes patients with moderate to severe AD in Germany. Baseline data of patients included into TREATgermany from inception in June 2016 to April 2020 in 39 sites across Germany was analyzed comparing AD disease characteristics and comorbidities in smokers versus non-smokers.

RESULTS

Of 921 patients, 908 (male: 58.7%) with a mean age of 41.9 ± 14.4 reported their smoking status. The objective Scoring of Atopic Dermatitis (oSCORAD) did not differ between smokers (n=352; 38.8%) and nonsmokers, however lesions' intensity of oozing/crusts and excoriations as well as patient global assessment scores (PGA) of AD severity were higher in smoking as opposed to nonsmoking patients. Smokers reported a lower number of weeks with well-controlled AD and more severe pruritus than nonsmokers. Total IgE levels were more elevated in smokers and they displayed a younger age at initial diagnosis of bronchial asthma. After adjustment for potential confounders, the increased intensity of oozing/crusts, the reduced number of weeks with well-controlled AD and the greater pruritus remained different in smokers compared to nonsmokers. In addition, smoking patients with adult-onset AD showed a 2.5 times higher chance of involvement of the feet.

CONCLUSIONS

German registry data indicate that AD patients who smoke have a higher disease burden with a different distribution pattern of lesions in adult-onset AD.

Different effects of smoking on atopic and non-atopic adult-onset asthma

BACKGROUND

Both tobacco smoking and atopy increase the risk of adult-onset asthma. We studied if there are differences in the effects of smoking on the risks of atopic and non-atopic adult-onset asthma, and if gender modifies these effects.

METHODS

The Finnish Environment and Asthma Study (FEAS) includes 521 incident cases of adult-onset asthma and 932 population-based controls, aged 21 to 63 years, recruited from a geographically defined area of Pirkanmaa, South Finland. Asthma was defined based on symptoms and lung function measurements, atopy by IgE antibodies to common aeroallergens and smoking by the study questionnaire.

RESULTS

Altogether 212 cases were atopic, and 251 cases were non-atopic. Regular smoking increased the risk of atopic asthma (adjusted OR 1.24, 95% CI 0.83-1.85), this effect was seen in women (aOR 1.77, 1.06-2.95) but not in men (aOR 0.75, 0.39-1.45). Among regular smokers, the amount smoked was lowest among women with atopic asthma. Recent quitting of smoking was related to increased risk of both atopic (aOR 4.91, 2.26-10.65) and non-atopic (aOR 4.37, 1.87-10.21) asthma. Having quitted smoking over a year ago was related to increased risk of non-atopic asthma (aOR 1.57, 1.08-2.28), mainly in men (aOR 2.03, 1.06-3.88).

CONCLUSIONS

In women, rather small amounts of regular smoking increase the risk of atopic asthma. However, for non-atopic asthma, the smoking induced risk continues for longer after quitting, especially in men. In conclusion, the effects of smoking on the risks of atopic and non-atopic asthma differ, and gender modifies these effects.

Importance of type and degree of IgE sensitisation for defining fractional exhaled nitric oxide reference values

BACKGROUND

Fractional exhaled nitric oxide (FE_NO) is a marker of type 2 airway inflammation used in clinical practice in asthma. However, reference values are needed to broaden the clinical use of FE_NO and this is within the scope of a newly started Global Lung Function Initiative task force. We aim to study FE_NO levels with special emphasis on the upper limit of normal (ULN) in relation to the type and degree of IgE sensitisation.

METHODS

FE_NO was measured in 1855 non-smoking, respiratory healthy subjects from the Swedish CArdioPulmonary bioImage Study (SCAPIS). Atopic subjects (n = 424), defined as being IgE-sensitised to aeroallergens (ImmunoCAP Phadiatop™, ≥0.35 PAU/l) were compared to non-atopic subjects (<0.35 PAU/l, n = 1431). Atopic subjects were further characterised according to their grade of IgE sensitisation (IgE antibody tertiles: (T1<1.16, T2 1.16-3.72 and T3 >3.72 PAU/l) and sensitisation to perennial (cat or mite) or seasonal (birch) allergens.

RESULTS

Subjects IgE-sensitised to cat or mite had higher FE_NO compared to non-atopic subjects (FE_NO (ppb): median 20.0 vs. 15.0, and ULN 50.4 vs. 33.0, p < 0.001). This was seen to a lesser extent for subjects IgE-sensitised to birch only (median 18.0 vs. 15.0, and ULN 38.0 vs. 33.0, p = 0.048). Atopic subjects with a high degree of IgE sensitisation (Phadiatop: >3.72 PAU/l) had the highest FE_NO compared to non-atopic subjects (median 20.0 vs. 15.0, and ULN 56.0 vs. 33.0, p < 0.001).

CONCLUSIONS

The type and degree of IgE sensitisation should be considered in generating FE_NO reference values.

Metabolic reprogramming: A driver of cigarette smoke-induced inflammatory lung diseases

Cigarette smoking is a well-known risk factor for pulmonary diseases, including chronic obstructive pulmonary disease (COPD), asthma and pulmonary fibrosis. Despite major progress in dissecting the mechanisms associated with disease development and progression, findings only represent one aspect of multifaceted disease. A crucial consequence of this approach is that many therapeutic treatments often fail to improve or reverse the disease state as other conditions and variables are insufficiently considered. To expand our understanding of pulmonary diseases, omics approaches, particularly metabolomics, has been emerging in the field. This strategy has been applied to identify putative biomarkers and novel mechanistic insights. In this review, we discuss metabolic profiles of patients with COPD, asthma, and idiopathic pulmonary fibrosis (IPF) with a focus on the direct effects of cigarette smoking in altering metabolic regulation. We next present cell- and animal-based experiments and point out the therapeutic potential of targeting metabolic reprogramming in inflammatory lung diseases. In addition, the obstacles in translating these findings into clinical practice, including potential adverse effects and limited pharmacological efficacy, are also addressed.

A prospective study on the role of smoking, environmental tobacco smoke, indoor painting and living in old or new buildings on asthma, rhinitis and respiratory symptoms

We studied associations between tobacco smoke, home environment and respiratory health in a 10 year follow up of a cohort of 11,506 adults in Northern Europe. Multilevel logistic regression models were applied to estimate onset and remission of symptoms. Current smokers at baseline developed more respiratory symptoms (OR = 1.39-4.43) and rhinitis symptoms (OR = 1.35). Starting smoking during follow up increased the risk of new respiratory symptoms (OR = 1.54-1.97) and quitting smoking decreased the risk (OR = 0.34-0.60). ETS at baseline increased the risk of wheeze (OR = 1.26). Combined ETS at baseline or follow up increased the risk of wheeze (OR = 1.27) and nocturnal cough (OR = 1.22). Wood painting at baseline reduced remission of asthma (OR 95%CI: 0.61, 0.38-0.99). Floor painting at home increased productive cough (OR 95%CI: 1.64, 1.15-2.34) and decreased remission of wheeze (OR 95%CI: 0.63, 0.40-0.996). Indoor painting (OR 95%CI: 1.43, 1.16-1.75) and floor painting (OR 95%CI: 1.77, 1.11-2.82) increased remission of allergic rhinitis. Living in the oldest buildings (constructed before 1960) was associated with higher onset of nocturnal cough and doctor diagnosed asthma. Living in the newest buildings (constructed 1986-2001) was associated with higher onset of nocturnal breathlessness (OR = 1.39) and rhinitis (OR = 1.34). In conclusion, smoking, ETS and painting indoor can be risk factors for respiratory symptoms. Wood painting and floor painting can reduce remission of respiratory symptoms. Smoking can increase rhinitis. Living in older buildings can be a risk factor for nocturnal cough and doctor diagnosed asthma. Living in new buildings can increase nocturnal dyspnoea and rhinitis.

Work-related Asthma in Crop Farmers

AIM: The objective of the study was to evaluate the influence of occupational exposure on asthma development among crop farmers. METHODS: A cross-sectional study was performed, comprising 87 crop farmers, and 80 office workers, matched by gender and age. Evaluation of subjects included completion of a standard questionnaire on chronic respiratory symptoms, spirometry tests, histamine challenge, serial peak expiratory flow rates (PEFR) measurements, and skin prick tests to occupational and common inhalant allergens. RESULTS: The prevalence of chronic respiratory symptoms in the past 12 months was higher, while the mean values of spirometric parameters were lower in crop farmers. Sensitization to workplace and common inhalant allergens was similar in both groups, whereas frequencies of bronchial hyperresponsiveness (BHR) and asthma were non-significantly higher in crop farmers. The prevalence of allergic was significantly higher compared to non-allergic asthma in both groups. Asthma was registered in 8% of crop farmers and was significantly associated with atopy, and positive family history of asthma. Occupational allergic asthma (OA) was registered in 2.3% of crop farmers, while the frequency of work-aggravated asthma was 5.7%. A causal relationship between workplace and asthma, suggesting allergic OA, was documented in two crop farmers with asthma, based on serial PEFR monitoring, but specific workplace agent causing asthma in the affected subjects was not identified. CONCLUSION: The obtained results can contribute in the detection of critical points for action, and serve as a predictive factor in the development of work-related asthma, indicating the need for reduction of adverse occupational exposures through adequate preventive measures, regular health examinations, obligatory use of respiratory protective equipment, and implementation of engineering controls.

Ambient air pollution and asthma onset in Taiwanese adults

BACKGROUND

Ambient nitrogen dioxide is associated with asthma occurrence in adults in Western countries. However, two recent large-scale studies have provided inconclusive results regarding this association. Moreover, the association remains unknown in an Asian population.

OBJECTIVE

We aimed to investigate the association between ambient air pollution exposure and incident adult asthma.

METHODS

From 2016 to 2017, we conducted a cross-sectional self-administered questionnaire survey with retrospective follow-up of incident asthma cases among schoolchildren's parents from 41 schools within 1 km of air monitoring stations distributed throughout the main island of Taiwan. To estimate participants' exposure, air pollution data of air monitoring stations within 1 km of schools from where participants were sampled were inputted into the proximity model. We used mixed logistic regression models to determine the association between air pollution exposure and asthma onset within five years prior to the survey.

RESULTS

The questionnaire was completed for a total of 11 585 participants out of 13 424 candidates (response rate, 86.3%). Among 9131 participants aged from 26 to 50 years, 101 were diagnosed with asthma within the five years prior to the survey. The prevalence of incident asthma cases was 2.2 per 1000 person-years. Those exposed to higher ambient nitrogen dioxide (odds ratio = 1.20 per interquartile [5.7 ppb] of nitrogen dioxide, 95% CI = 1.02-1.42) were more likely to develop adult-onset asthma.

CONCLUSION

In an Asian population, exposure to higher ambient nitrogen dioxide is associated with increased prevalence of incident asthma cases among adults aged 26-50 years.

Impact of Air Pollution on Asthma Outcomes

Asthma is a chronic respiratory disease characterized by variable airflow obstruction, bronchial hyperresponsiveness, and airway inflammation. Evidence suggests that air pollution has a negative impact on asthma outcomes in both adult and pediatric populations. The aim of this review is to summarize the current knowledge on the effect of various outdoor and indoor pollutants on asthma outcomes, their burden on its management, as well as to highlight the measures that could result in improved asthma outcomes. Traffic-related air pollution, nitrogen dioxide and second-hand smoking (SHS) exposures represent significant risk factors for asthma development in children. Nevertheless, a causal relation between air pollution and development of adult asthma is not clearly established. Exposure to outdoor pollutants can induce asthma symptoms, exacerbations and decreases in lung function. Active tobacco smoking is associated with poorer asthma control, while exposure to SHS increases the risk of asthma exacerbations, respiratory symptoms and healthcare utilization. Other indoor pollutants such as heating sources and molds can also negatively impact the course of asthma. Global measures, that aim to reduce exposure to air pollutants, are highly needed in order to improve the outcomes and management of adult and pediatric asthma in addition to the existing guidelines.

Study of atopic multimorbidity in subjects with rhinitis using multiplex allergen component analysis

BACKGROUND

Rhinitis is a common problem within the population. Many subjects with rhinitis also have atopic multimorbidity, such as asthma and eczema. The purpose of this investigation was to compare subjects with only rhinitis to those that have rhinitis, asthma and/or eczema in relation to immunoglobulin E (IgE) sensitization, inflammatory markers, family history, lung function and body mass index (BMI).

METHODS

A total of 216 adult subjects with rhinitis from the European Community Respiratory Health Survey II were investigated with multiplex component allergen analysis (103 allergen components), total IgE, C-reactive protein, eosinophilic cationic protein, fractional exhaled nitric oxide and spirometry. Rhinitis, eczema, asthma and parental allergy were questionnaire-assessed.

RESULTS

Of the 216 participants with rhinitis, 89 also had asthma and/or eczema. Participants with rhinitis that also had asthma or eczema were more likely to be IgE-sensitized (3.44, odds ratio, OR: 95% CI 1.62-7.30, adjusted for sex, age, mother's allergy, total IgE and forced expiratory volume (FEV1)). The number of IgE-positive components was independently associated with atopic multimorbidity (1.11, OR: 95% Cl 1.01-1.21) adjusted for sex, age, mother's allergy, total IgE and FEV1. When analysing different types of sensitization, the strongest association with atopic multimorbidity was found in participants that were IgE-sensitized both to perennial and seasonal allergens (4.50, OR: 95% CI 1.61-12.5). Maternal allergy (2.75, OR: 95% CI 1.15-4.46), high total IgE (2.38, OR: 95% CI 1.21-4.67) and lower FEV1 (0.73, OR: 95% CI 0.58-0.93) were also independently associated with atopic multimorbidity, while no association was found with any of the other inflammatory markers.

CONCLUSION

IgE polysensitization, to perennial and seasonal allergens, and levels of total IgE seem to be the main determinants of atopic multimorbidity in subjects with rhinitis. This indicates that disease-modifying treatment that targets IgE sensitization may be of value when decreasing the risk of developing atopic multimorbidity.

The association between e-cigarette use and asthma among never combustible cigarette smokers: behavioral risk factor surveillance system (BRFSS) 2016 & 2017

BACKGROUND

E-cigarette use prevalence has grown rapidly in the US. Despite the popularity of these products, few acute exposure toxicity studies exist, and studies on long-term pulmonary health effects are limited. E-cigarette users who are never combustible cigarette smokers (sole users) constitute a unique group of young adults that may be at increased risk of bronchial hyperreactivity and development of asthma. Given the public health concern about the potential pulmonary health effects of sole e-cigarette use, we aimed to examine the association between e-cigarette use and asthma among never combustible cigarette smokers.

METHODS

We pooled 2016 and 2017 data of the Behavioral Risk Factor Surveillance System (BRFSS), a large, cross-sectional telephone survey of adults aged 18 years and older in the U.S. We included 402,822 participants without any history of combustible cigarette smoking (defined as lifetime smoking < 100 cigarettes) and with complete self-reported information on key variables. Current e-cigarette use, further classified as daily or occasional use, was the primary exposure. The main outcome, asthma, was defined as self-reported history of asthma. We assess the relationship of sole e-cigarette use with asthma using multivariable logistic regression adjusting for age, sex, race, income, level of education and body mass index.

RESULTS

Of 402,822 never combustible cigarette smokers, there were 3103 (0.8%) current e-cigarette users and 34,074 (8.5%) with asthma. The median age group of current e-cigarette users was 18-24 years. Current e-cigarette use was associated with 39% higher odds of self-reported asthma compared to never e-cigarette users (Odds Ratio [OR], 1.39; 95% confidence interval: 1.15, 1.68). There was a graded increased odds of having asthma with increase of e-cigarette use intensity. The odds ratio of self-reported asthma increased from 1.31 (95% confidence interval: 1.05, 1.62) in occasional users to 1.73 (95% confidence interval: 1.21, 2.48) in daily e-cigarette users, compared to never e-cigarette users.

CONCLUSION

Our findings from a large, nationally representative survey suggest increased odds of asthma among never combustible smoking e-cigarette users. This may have potential public health implications, providing a strong rationale to support future longitudinal studies of pulmonary health in young e-cigarette-using adults.

Dampness, mould, onset and remission of adult respiratory symptoms, asthma and rhinitis

STUDY QUESTION

Is dampness and indoor mould associated with onset and remission of respiratory symptoms, asthma and rhinitis among adults?

MATERIALS AND METHODS

Associations between dampness, mould and mould odour at home and at work and respiratory health were investigated in a cohort of 11 506 adults from Iceland, Norway, Sweden, Denmark and Estonia. They answered a questionnaire at baseline and 10 years later, with questions on respiratory health, home and work environment.

RESULTS

Baseline water damage, floor dampness, mould and mould odour at home were associated with onset of respiratory symptoms and asthma (OR 1.23-2.24). Dampness at home during follow-up was associated with onset of respiratory symptoms, asthma and rhinitis (OR 1.21-1.52). Dampness at work during follow-up was associated with onset of respiratory symptoms, asthma and rhinitis (OR 1.31-1.50). Combined dampness at home and at work increased the risk of onset of respiratory symptoms and rhinitis. Dampness and mould at home and at work decreased remission of respiratory symptoms and rhinitis.

THE ANSWER TO THE QUESTION

Dampness and mould at home and at work can increase onset of respiratory symptoms, asthma and rhinitis, and decrease remission.

Long-term Breastfeeding in the Prevention of Allergic Rhinitis: Allergic Rhinitis Cohort Study for Kids (ARCO-Kids Study)

OBJECTIVES

There is a great deal of interest in the possibility that environmental factors may influence the risk of developing allergic rhinitis (AR) in early life. We investigated the simultaneous effects of mode of delivery and duration of breastfeeding on the development of AR in children.

METHODS

Data from 1,374 children participating in the Allergic Rhinitis Cohort Study for kids (ARCO-kids study) was analyzed. All subjects were divided into AR or non-allergic rhinitis (NAR) groups. Data on environmental factors, mode of delivery and duration of breastfeeding were collected using a questionnaire.

RESULTS

Compared with short-term breastfeeding (<6 months), long-term breastfeeding (≥12 months) was significantly associated with a lower prevalence of AR (adjusted odds ratio [aOR], 0.54; 95% confidence interval [CI], 0.34 to 0.88). Children in the AR group also had a higher cesarean delivery rate than those in the NAR group (39.1% vs. 32.8%, P=0.05). Regarding the combined effects of mode of delivery and duration of breastfeeding, long-term breastfeeding with a vaginal delivery strongly suppressed the development of AR, compared to short-term breastfeeding with a cesarean delivery (aOR, 0.47; 95% CI, 0.30 to 0.73).

CONCLUSION

Long-term breastfeeding (≥12 months) and a vaginal delivery are associated with a lower risk of developing childhood AR.

New-Onset Asthma in Adults: What Does the Trigger History Tell Us?

BACKGROUND

Adult-onset asthma is an important asthma phenotype and, in contrast to childhood asthma, is often associated with specific triggers of onset. It is unknown whether these triggers correspond with specific phenotypic characteristics or predict a specific asthma outcome.

OBJECTIVE

To compare clinical, functional, and inflammatory characteristics between patients with different triggers of asthma onset, and relate these triggers to asthma outcome.

METHODS

Two hundred adults with recently diagnosed (<1 year) asthma were prospectively followed for 5 years. The trigger of asthma onset was patient reported and defined by the question: "What, in your opinion, elicited your asthma?" Asthma remission was defined as no asthma symptoms and no asthma medication use for ≥1 year. Kruskal-Wallis and Fisher's exact test were used to compare categories containing >10 patients.

RESULTS

Ten categories of triggers were identified, of which 5 contained >10 patients. Clinical and inflammatory characteristics and remission rates differed significantly between categories. "New allergic sensitization" (11%) was associated with mild atopic asthma and a relatively young age at onset; "pneumonia" (8%) with previous smoking, low IgE, and the highest remission rates (one third); "upper respiratory symptoms" (22%) with high exhaled NO and eosinophilia; "no trigger identified" (38%) did not show any specific characteristics; and "stressful life event" (7%) with high medication usage, low type 2 markers, and no disease remission.

CONCLUSIONS

Patients with adult-onset asthma can be characterized by the trigger that seemingly incited their asthma. These triggers might represent underlying mechanisms and may be important to phenotype patients and predict disease outcome.

NOx in exhaled breath condensate is related to allergic sensitization in young and middle-aged adults

BACKGROUND

Asthma and allergic diseases are heterogeneous. Measurement of biomarkers in exhaled breath condensate (EBC) may help to discriminate between different phenotypes and may assist with clinical prognostication.

OBJECTIVES

We aimed to assess associations between total nitric oxide products (NO_x ) in EBC and different allergic phenotypes and lung function in young and middle-aged adults.

METHODS

Cross-sectional analyses were nested within two Australian longitudinal studies, the Melbourne Atopy Cohort Study (MACS, mean age 17.8 years) and the Tasmanian Longitudinal Health Study (TAHS, mean age 49.4 years). Levels of EBC NO_x were determined by Griess-reaction fluorescent method. Associations were assessed between EBC NO_x and different allergic phenotypes, lung function and airway reactivity.

RESULTS

Atopy, with or without asthma or rhinitis, was associated with increased EBC NO_x levels particularly in individuals with poly-aero-sensitization. These findings were generally consistent across the two age groups. In the older cohort, use of ICS in the previous 12 months masked the association between sensitization and EBC NO_x (OR = 0.64, 95% CI = 0.21-1.96, p for interaction = 0.05).

CONCLUSIONS AND CLINICAL RELEVANCE

In these population-based samples, EBC NO_x was most strongly associated with atopic sensitization, rather than either current asthma or rhinitis, possibly indicating underlying increased airway inflammation associated with atopy. Therefore, EBC NO_x could be a key predictor of atopy in both young and middle-aged adults, regardless of the presence of concomitant asthma or rhinitis.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Smoking Cessation as a Possible Risk Factor for the Development of Aspirin-Exacerbated Respiratory Disease in Smokers

BACKGROUND

The pathogenesis of aspirin-exacerbated respiratory disease (AERD) is characterized by the low expression of cyclooxygenase-2 (COX-2) in airway epithelia, which decreases the production of prostaglandin E₂ (PGE₂). Conversely, cigarette smoke stimulates COX-2 expression in airway epithelia. Therefore, it was hypothesized that the development of AERD would be suppressed by elevated PGE₂ levels in smokers, and smoking cessation might increase susceptibility to AERD.

OBJECTIVE

The objective of this study was to evaluate the relationship between smoking and the risk of AERD development.

METHODS

The smoking status of patients with AERD (n = 114) was compared with 2 control groups with aspirin-tolerant asthma (ATA), patients diagnosed by a systemic aspirin provocation test (ATA-1, n = 83) and outpatients randomly selected from a large-scale dataset (ATA-2, n = 914), as well as a healthy control group (HC, n = 2313).

RESULTS

At the age of asthma onset, there was a low frequency of current smokers (9.7%), but a high frequency of past smokers (20.2%) in the AERD group compared with the ATA-1 (20.5% and 12.0% for current and past smokers, respectively), ATA-2 (24.5% and 10.3%, respectively), and HC group (26.2% and 12.6%, respectively). After adjustment for confounding variables, AERD was positively associated with smoking cessation between 1 and 4 years before disease onset compared with the ATA-2 group (adjusted odds ratio [aOR] 4.63, 95% confidence interval [CI]: 2.16-9.93) and the HC group (aOR 4.09, 95% CI: 2.07-8.05), implying that smoking cessation was followed by the development of AERD.

CONCLUSION

Smoking cessation may be a risk factor for the development of AERD.

Course of respiratory allergy by treatment strategy based on German routine data

Purpose

Allergic respiratory diseases represent a global health problem. The two major treatment strategies are symptom treatment and specific immunotherapy (SIT). SIT is considered the only causal treatment option available with the ability to alter the course of the disease. This study aims to describe the course of disease and medication of respiratory allergy across treatment strategies and disease groups.

Methods

The analysis is based on routine data from a German statutory health insurance. The patient cohort is observed from 2007–2012. For each year based on assured outpatient diagnoses patients are assigned to a disease group: rhinitis, asthma or both diseases. Additionally, prescribed medication is considered. Treatment comparisons are based on matched pairs.

Results

The study population comprises 165,446 patients with respiratory allergy. In 2007 the most frequent disease group is rhinitis (70%), followed by asthma (16%) and both diseases (14%). During the observation period a second allergic respiratory diagnosis occurs only in about 12% of rhinitis patients and 28% of asthma patients. In about 50% of patients with both diseases one of the diagnoses is omitted. These patients are more likely to no longer report their asthma diagnosis when receiving immunotherapy compared to symptom treatment. Furthermore immunotherapy reduces the frequency of asthma medication use.

Conclusions

Results of detailed analysis of diagnoses reflect the alternating nature of allergic diseases. Although limited by accuracy of documentation and the lack of clinical information, the comparison of treatment strategies shows some advantages of immunotherapy regarding course of disease and asthma medication use.

Impacts of oak pollen on allergic asthma in the United States and potential influence of future climate change

Future climate change is expected to lengthen and intensify pollen seasons in the U.S., potentially increasing incidence of allergic asthma. We developed a proof-of-concept approach for estimating asthma emergency department (ED) visits in the U.S. associated with present-day and climate-induced changes in oak pollen. We estimated oak pollen season length for moderate (Representative Concentration Pathway (RCP) 4.5) and severe climate change scenarios (RCP8.5) through 2090 using five climate models and published relationships between temperature, precipitation, and oak pollen season length. We calculated asthma ED visit counts associated with 1994-2010 average oak pollen concentrations and simulated future oak pollen season length changes using the Environmental Benefits Mapping and Analysis Program, driven by epidemiologically derived concentration-response relationships. Oak pollen was associated with 21,200 (95% confidence interval, 10,000-35,200) asthma ED visits in the Northeast, Southeast, and Midwest U.S. in 2010, with damages valued at $10.4 million. Nearly 70% of these occurred among children age <18 years. Severe climate change could increase oak pollen season length and associated asthma ED visits by 5% and 10% on average in 2050 and 2090, with a marginal net present value through 2090 of $10.4 million (additional to the baseline value of $346.2 million). Moderate versus severe climate change could avoid >50% of the additional oak pollen-related asthma ED visits in 2090. Despite several key uncertainties and limitations, these results suggest that aeroallergens pose a substantial U.S. public health burden, that climate change could increase U.S. allergic disease incidence, and that mitigating climate change may have benefits from avoided pollen-related health impacts.

Current asthma, respiratory symptoms and airway infections among students in relation to the school and home environment in Japan

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.

Smoking and New-Onset Asthma in a Prospective Study on Italian Adults

BACKGROUND

The existence of a cause-effect relation between active smoking and new-onset asthma in adults, although supported by several studies, has not been proven yet.

AIMS

We aimed to prospectively study asthma incidence as a function of smoking habits in the Italian adult population.

METHODS

A population-based cohort of 5,241 non-asthmatics was enrolled in Verona and Sassari in 1998-2000. The cohort was contacted again in 2007-2009 within the Gene-Environment Interactions in Respiratory Diseases study, and 3,187 subjects (60.8%) answered a screening questionnaire on smoking habits and respiratory disorders. The relation between smoking habits and self-reported new-onset asthma, defined as asthma attacks/use of medicines for asthma, was investigated by a multivariable logistic model.

RESULTS

During follow-up, 145 new cases of asthma were observed, yielding a cumulative incidence of 4.6% (95% CI 3.9-5.4); cumulative incidence of asthma did not significantly differ among never-smokers (76/1,666 = 4.6%), ex-smokers (30/554 = 5.4%) and current smokers (39/883 = 4.4%) (p = 0.641). In a multivariable analysis, the most important risk factor for asthma onset was allergic rhinitis (OR = 4.00, 95% CI 3.68-4.35). Compared to never-smokers, the risk of asthma onset was slightly increased in ex-smokers (OR = 1.28, 1.09-1.49) but not in current smokers (OR 1.01, 0.66-1.53). Current smoking became a significant predictor only when both new-onset wheezing and new-onset asthma were considered as the outcome (OR = 2.03, 1.35-3.05).

CONCLUSIONS

In this prospective study, current smoking was not a risk factor for new-onset asthma, unless new-onset wheezing was also considered. The increase in asthma incidence among ex-smokers was likely due to reverse causation.

High occurrence of rhinitis symptoms in hairdressing apprentices

BACKGROUND

Little is known about the occurrence of respiratory symptoms among hairdressing apprentices during their training. Therefore, in this study, we examined whether hairdressing apprentices are at increased risk of rhinitis and asthma symptoms when compared with other young adults from the general population.

METHODS

A questionnaire was completed by 504 hairdressing apprentices and 1400 control participants from the general population with a similar age, gender, and geographic distribution.

RESULTS

The 1-year prevalence of rhinitis symptoms was higher in hairdressing apprentices than in controls (58.1% vs 46.6%; odds ratio, 1.59; 95% confidence interval, 1.30-1.98), and the prevalence was higher among hairdressing apprentices in the last years of training compared with apprentices in the first year of training (62.4% vs 41.8%, p = 0.003). Current smoking was more common in hairdressing apprentices (28.4% vs 17.2%, p < 0.001). Asthma symptoms were equally common in the 2 groups; however, hairdressing apprentices had a later age of onset of wheezing than did the controls (18 years vs 14 years, p < 0.00001) and a decreased risk of wheezing (odds ratio, 0.72; 95% confidence interval, 0.54 to 0.95) after adjusting for smoking, education level, and degree of rurality. Bleaching products were the most frequently reported cause of rhinitis and asthma symptoms in hairdressing apprentices.

CONCLUSIONS

Hairdressing apprentices seem to have an increased risk of occupational rhinitis, and bleaching products are the main cause of respiratory symptoms. In addition, our findings suggest that a healthy worker effect exists in relation to asthma among hairdressing apprentices.

Patient stratification and the unmet need in asthma

Asthma is often described as an inflammatory disease of the lungs and in most patients symptomatic treatment with bronchodilators or inhaled corticosteroids is sufficient to control disease. Unfortunately there are a proportion of patients who fail to achieve control despite treatment with the best current treatment. These severe asthma patients have been considered a homogeneous group of patients that represent the unmet therapeutic need in asthma. Many novel therapies have been tested in unselected asthma patients and the effects have often been disappointing, particularly for the highly specific monoclonal antibody-based drugs such as anti-IL-13 and anti-IL-5. More recently, it has become clear that asthma is a syndrome with many different disease drivers. Clinical trials of anti-IL-13 and anti-IL-5 have focused on biomarker-defined patient groups and these trials have driven the clinical progression of these drugs. Work on asthma phenotyping indicates that there is a group of asthma patients where T helper cell type 2 (Th2) cytokines and inflammation predominate and these type 2 high (T2-high) patients can be defined by biomarkers and response to therapies targeting this type of immunity, including anti-IL-5 and anti-IL-13. However, there is still a subset of T2-low patients that do not respond to these new therapies. This T2-low group will represent the new unmet medical need now that the T2-high-targeting therapies have made it to the market. This review will examine the current thinking on patient stratification in asthma and the identification of the T2-high subset. It will also look at the T2-low patients and examine what may be the drivers of disease in these patients.

Role of individual-housing-based socioeconomic status measure in relation to smoking status among late adolescents with asthma

PURPOSE

We aimed to assess whether smoking status among individuals in late adolescence (19-22 years) with asthma was associated with socioeconomic status (SES) defined by HOUSES, an individual-housing-based SES measure.

METHODS

A population-based cross-sectional study was conducted among the 1988-1989 Olmsted County, Minnesota Birth Cohort, with physician-diagnosed asthma and that lived in the community during the study period (November 1, 2008-October 31, 2012). Using a z score for housing value, actual square footage, and numbers of bedrooms and bathrooms, HOUSES was formulated and categorized into quartiles. Smoking status (both current and past smoker) was compared among subjects with different SES as measured by HOUSES using logistic regression, adjusting for age and sex.

RESULTS

Among 289 eligible subjects, 287 (99%) were successfully geo-coded to real property data for HOUSES. Of the 257 subjects whose smoke exposure was recorded, 70 (27%) had a history of smoking (either past or current). An inverse association was observed between HOUSES and smoking status after accounting for age, gender, and General Medical Examination status (adjusted OR = 0.39, 95% CI = 0.18-0.87 for comparing highest vs. lowest HOUSES in quartile; overall P = .02).

CONCLUSIONS

A significant proportion of individuals with asthma in late adolescence was smokers during the study period, disproportionally affecting those with lower SES.

Asthma risk factors

BACKGROUND

Bronchial asthma is one of the most common chronic diseases in childhood, with a current prevalence of 6% to 9%, but a prevalence that is increasing at an alarming rate. Asthma is a complex genetic disorder with strong environmental influence. It imposes a growing burden on our society in terms of morbidity, quality of life, and healthcare costs. Despite large-scale efforts, only a few asthma genes have been confirmed, suggesting that the genetic underpinning of asthma is highly complex.

METHODS

A review of the literature was performed regarding atopic and nonatopic asthma risk factors, including environmental risk factors and genetic studies in adults and children.

RESULTS

Several environmental risk factors have been identified to increase the risk of developing asthma such as exposure to air pollution and tobaccos smoke as well as occupational risk factors. In addition atopy, stress, and obesity all can increases the risk for asthma in genetically susceptible persons.

CONCLUSION

Asthma represents a dysfunctional interaction with our genes and the environment to which they are exposed, especially in fetal and early infant life. The increasing prevalence of asthma in all age groups indicate that our living environment and immunity are in imbalance with each other reacting with airway inflammation to the environmental exposures and often non-harmful proteins, such as allergens causing the current "asthma and allergy epidemic." Because of the close relationship between asthma and chronic rhinosinusitis, it is important that otolaryngologists have a good understanding of asthma, the etiologic factors associated with disease, and its evaluation and management.

Adverse Childhood Events are Related to the Prevalence of Asthma and Chronic Obstructive Pulmonary Disorder Among Adult Women in Hawaii

PURPOSE

In the US, women surpass men in the prevalence of lung diseases. Limited studies exist on the association of adverse childhood events (ACEs) to asthma and chronic obstructive pulmonary disorder (COPD) particularly among women and cohorts of understudied populations (e.g., Pacific Islanders). This study evaluated the ACEs-asthma and ACEs-COPD relationships among women in Hawaii and the contribution of poor health factors (smoking, binge drinking, and obesity) in these associations.

METHODS

Using data from 3363 women in the Behavioral Risk Factor Surveillance System-Hawaii, we assessed how self-reported ACEs [count and type (household dysfunction, and physical, verbal and sexual abuse)] relate to asthma and COPD. Multivariable log-binomial regression, accounting for the sampling design, and model adjustments for socio-demographics, healthcare access, emotional support, current smoking, binge drinking, and BMI status were used to generate prevalence ratios.

RESULTS

For every increase in ACE count, the likelihood for asthma increased by 7 % (CI = 1.02-1.13), and for COPD, by 21 % (CI = 1.12-1.31) accounting for socio-demographics, healthcare access, and emotional support. Verbal abuse was also associated with greater likelihood for asthma independent of these covariates (PR = 1.43, CI = 1.14-1.79). Household dysfunction (PR = 1.82, CI = 1.15-2.82) and physical (PR = 2.01, CI = 1.20-3.37), verbal (PR = 2.24, CI = 1.38-3.65) and sexual (PR = 1.81, CI = 1.10-2.97) abuse were all associated with COPD using similar adjustments. Additional adjustment for smoking, binge drinking, and BMI status did not impact the ACE-asthma associations and only modestly attenuated the ACE-COPD relationships.

CONCLUSIONS

Primary and secondary prevention of ACEs may optimize the health of young girls in Hawaii, and reduce the burden of asthma and COPD among women in the state.

Allergic sensitization is age-dependently associated with rhinitis, but less so with asthma

BACKGROUND

Epidemiologic data describing the association between allergic sensitization and asthma and allergic rhinitis in adults are scarce.

OBJECTIVE

To determine the prevalence and impact of specific sensitization to airborne allergens on asthma and allergic rhinitis among adults in relation to age.

METHODS

A random population sample (age 21-86 years) was examined with structured interview and analysis of specific IgE to 9 common airborne allergens. Of those invited, 692 (68%) subjects participated in blood sampling. IgE level of 0.35 U/mL or more to the specific allergen was defined as a positive test result.

RESULTS

Allergic sensitization decreased with increasing age, both in the population sample and among subjects with asthma and allergic rhinitis. In a multivariate model, sensitization to animal was significantly positively associated with asthma (odds ratio [OR], 4.80; 95% CI, 2.68-8.60), whereas sensitization to both animal (OR, 3.90; 95% CI, 2.31-6.58) and pollen (OR, 4.25; 95% CI, 2.55-7.06) was significantly associated with allergic rhinitis. The association between allergic sensitization and rhinitis was consistently strongest among the youngest age group, whereas this pattern was not found for asthma. The prevalence of allergic sensitization among patients with asthma decreased by increasing age of asthma onset, 86% with asthma onset at age 6 y or less, 56% at age 7 to 19 years, and 26% with asthma onset at age 20 years or more.

CONCLUSIONS

Sensitization to animal was associated with asthma across all age groups; allergic rhinitis was associated with sensitization to both pollen and animal and consistently stronger among younger than among older adults. Early onset of asthma was associated with allergic sensitization among adults with asthma.

Effect of Nasal Allergy Over Spirometric Parameters: A Prospective Study

Nasal allergy is characterized by an IgE mediated inflammatory response of nasal mucosa to allergens and it has a close association with Asthma. Nasal allergy has been demonstrated to be a strong risk factor for the onset of asthma in adults. Spirometric parameters like Forced expiratory volume at timed interval of 1 s (FEV1) and forced expiratory flow (FEF25-75 %) are impaired in patients with nasal allergy or allergic rhinitis. The FEF25-75 % has been evidenced to be a reliable marker of early bronchial impairment in nasal allergy. Nasal allergy may be considered as the first step of the progression of respiratory allergy towards asthma. It has been demonstrated that FEF25-75 % is useful in predicting the presence of airway hyper responsiveness.It may be a more sensitive indicator of chronic airway obstruction than FEV1 and is considered as a risk factor for the persistence of respiratory symptoms in asthmatic patients. The impact of allergic rhinitis or nasal allergy on asthma (ARIA) guidelines, clearly underlined the role of allergic rhinitis as risk factor for asthma development. The possible presence of spirometric abnormalities in patient with allergic rhinitis has been well documented. So keeping this in mind, present study is undertaken to evaluate the impairment of spirometric parameters, like FEV1, FEF25-75 %, and forced vital capacity, in patients with nasal allergy and to predict the presence of airway hyper responsiveness.

Prognosis of adult asthma: a 7-year follow-up study

BACKGROUND

Studies on adult-onset asthma and the contributing factors for its prognosis are few in the literature.

OBJECTIVE

To evaluate asthma prognosis, remission rate, and contributing factors in an adult patient population.

METHODS

Two hundred patients with a diagnosis of adult-onset asthma in 2006 were included in this study. Of these, 160 were contacted in 2013 and participated in the study. Their demographic features, family history, clinical symptoms, pulmonary function test results, and Asthma Control Test scores were re-evaluated. Patients' asthma control status was determined. Patients who had total control and had not used any asthma treatment for at least 2 years were classified as in remission.

RESULTS

The study group consisted of 160 patients (144 women and 16 men, mean age 52.9 ± 10.3 years). Nearly 70% of patients had adult-onset asthma before 40 years of age. According to asthma control status, 21.9% of patients had uncontrolled asthma, 29.4% had partially controlled asthma, and 48.8% had totally controlled asthma. Remission was observed in 11.3% of the entire study group. The mean age of the remission group was significantly younger. Disease duration was shorter and the proportion of patients with atopy was larger in the totally controlled and remission groups. Except in the remission group, patients showed weight gain from 2006 through 2013.

CONCLUSION

According to these 7-year follow up data, the remission rate of asthma was 11.3%. Patients with younger age, younger onset, atopy, allergic rhinitis, and few comorbidities seemed to have a greater possibility of remission.

Active and passive smoking and the incidence of asthma in the Black Women's Health Study

RATIONALE

Evidence linking active or passive smoking to the incidence of adult-onset asthma is inconsistent with both positive and inverse associations being reported. Most previous studies of active smoking have not accounted for passive smoke exposure, which may have introduced bias.

OBJECTIVES

To assess the separate associations of active and passive smoking to the incidence of adult-onset asthma in the U.S. Black Women's Health Study, a prospective cohort of African American women followed since 1995 with mailed biennial questionnaires.

METHODS

Active smoking status was reported at baseline and updated on all follow-up questionnaires. Passive smoke exposure during childhood, adolescence, and adulthood was ascertained in 1997. Asthma cases comprised women who reported doctor-diagnosed asthma with concurrent asthma medication use. Cox regression models were used to derive multivariable hazard ratios (HRs) and 95% confidence intervals (CIs) for former and current smoking and for passive smoking among nonsmokers compared with a reference category of never active or passive smokers.

MEASUREMENTS AND MAIN RESULTS

Among 46,182 participants followed from 1995 to 2011, 1,523 reported incident asthma. The multivariable HRs for former active smoking, current active smoking, and passive smoking only were, respectively, 1.36 (95% CI, 1.11-1.67), 1.43 (95% CI, 1.15-1.77), and 1.21 (95% CI, 1.00-1.45), compared with never active/passive smoking.

CONCLUSIONS

In this large population with 16 years of follow-up, active smoking increased the incidence of adult-onset asthma, and passive smoke exposure increased the risk among nonsmokers. Continued efforts to reduce exposure to tobacco smoke may have a beneficial effect on the incidence of adult-onset asthma.

Reduced severity and improved control of self-reported asthma in Finland during 2001-2010

Background

Asthma and allergies are common and cause substantial burden in symptoms and suffering, hospitalizations and medication costs. However, despite the high prevalence, asthma burden has already decreased in Finland in 2000s.

Objective

We carried out an asthma barometer survey in all Finnish pharmacies to study changes in asthma severity and control, and use of health care services from 2001 to 2010.

Methods

Asthma severity, comorbid allergic conditions, and use of medication and health care services were assessed in subjects who purchased asthma or allergy medication from the pharmacies all across the country during one week in 2001 and again in 2010. In 2001, 3,062 patients (mean age, 49 years), and in 2010, 1,114 patients (mean age, 51 years) participated.

Results

In 2001 90% and in 2010 73% of the respondents reported physician-diagnosed asthma and were entitled to special reimbursement for their drug costs, i.e., they needed regular maintenance treatment. In 2001, 10% of the asthmatics regarded their disease as severe, compared with 4% in 2010, while the figures for mild asthma were 45% and 62%, respectively (p < 0.001). The proportion of patients needing emergency care during the last year decreased from 34% (2001) to 14% (2010) (p < 0.001) and the need for hospitalizations from 18% to 6% (p < 0.001). Smoking reduced from 24% to 18% among asthmatics ( p = 0.002). In 2010, risk factors for severe asthma were older age, comorbid atopic eczema, and food allergy.

Conclusion

During ten years, self-reported asthma severity has reduced and disease control improved in Finland.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Developing and emerging clinical asthma phenotypes

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

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

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