Correlation between work impairment, scores of rhinitis severity and asthma using the MASK-air® App

BACKGROUND

In allergic rhinitis, a relevant outcome providing information on the effectiveness of interventions is needed. In MASK-air (Mobile Airways Sentinel Network), a visual analogue scale (VAS) for work is used as a relevant outcome. This study aimed to assess the performance of the work VAS work by comparing VAS work with other VAS measurements and symptom-medication scores obtained concurrently.

METHODS

All consecutive MASK-air users in 23 countries from 1 June 2016 to 31 October 2018 were included (14 189 users; 205 904 days). Geolocalized users self-assessed daily symptom control using the touchscreen functionality on their smart phone to click on VAS scores (ranging from 0 to 100) for overall symptoms (global), nose, eyes, asthma and work. Two symptom-medication scores were used: the modified EAACI CSMS score and the MASK control score for rhinitis. To assess data quality, the intra-individual response variability (IRV) index was calculated.

RESULTS

A strong correlation was observed between VAS work and other VAS. The highest levels for correlation with VAS work and variance explained in VAS work were found with VAS global, followed by VAS nose, eye and asthma. In comparison with VAS global, the mCSMS and MASK control score showed a lower correlation with VAS work. Results are unlikely to be explained by a low quality of data arising from repeated VAS measures.

CONCLUSIONS

VAS work correlates with other outcomes (VAS global, nose, eye and asthma) but less well with a symptom-medication score. VAS work should be considered as a potentially useful AR outcome in intervention studies.

Perfluoroalkyl substances, airways infections, allergy and asthma related health outcomes - implications of gender, exposure period and study design

INTRODUCTION

Exposure to perfluoroalkyl substances (PFASs) has been inconsistently associated with asthma, allergic diseases and airways infections in early childhood. The aim of the study was, therefore, to investigate the effect of childhood exposure to PFASs on asthma and allergy related outcomes and on airways infections before and during puberty using the prospective birth cohort Environment and Childhood Asthma (ECA) Study. Aspects of gender, exposure period and study design (cross-sectional and longitudinal) were also taken into consideration.

MATERIAL AND METHODS

Included in the study was 378 participants with PFAS measurements at age 10 years and follow-up data at ages 10 years (cross sectional data) and 16 years (longitudinal data). Eight PFASs with at least 70% of measurements above the limit of quantification (LOQ) in the child's serum were included in the present study: perfluoroheptanoate (PFHpA), perfluorooctanoate (PFOA), perfluourononanoate (PFNA), perfluorodecanoate (PFDA), perfluoroundecanoate (PFUnDA), perfluorohexane sulfonate (PFHxS), perfluoroheptane sulfonate (PFHpS) and perfluorooctane sulfonate (PFOS). The PFAS levels were converted into interquartile range (IQR). In addition, perfluorooctane sulfonamide (PFOSA) detected in 60% of the samples, was recoded into "not detected /detected". Binomial, multinomial and linear regression were used, followed by Bonferroni adjustment to correct for multiple comparisons. Sensitivity analyses evaluating the effect of extreme PFAS values and gender were performed.

RESULTS

In the cross sectional data at 10 years a positive statistically significant association was seen between PFHpA and asthma in girls. In the longitudinal data, PFNA, PFDA and PFUnDA were inversely associated with atopic dermatitis (AD) in girls and with PFHxS in all participants and in boys. Further, PFNA and PFHpS were positively associated with rhinitis in girls and with PFOA in all participants. There seems to be a suggestive pattern of increased risk of allergic sensitisation in all participants and a decreased risk in boys, but due to different results in main and sensitivity analyses these findings should be interpreted with caution. No associations were found between PFASs and lung function. For airways infections and longitudinal data, PFDA was inversely associated with common cold, while positive association was found for PFHpA, PFOA, PFHpS and PFOS and lower respiratory tract infections (LRTI).

DISCUSSION AND CONCLUSION

Our results lend further support for an immunosuppressive effect of PFASs on AD and LRTI. Gender seems to be important for some exposure-health associations. No clear pattern in exposure-health associations was observed with regard to exposure period or study design, with the exception of asthma where significant findings have mostly been reported in cross-sectional studies.

An update on prevalence and risk of snus and nicotine replacement therapy during pregnancy and breastfeeding

AIM

In parallel with falling smoking rates, use of the oral moist tobacco product snus increases among women in reproductive age. We report an update on prevalence and effects of maternal use of snus and nicotine replacement therapy (NRT) during pregnancy and breastfeeding.

METHODS

A literature search of human studies in Medline, PubMed and EMBASE was conducted from September 2016 to May 2018, with stepwise screening of abstracts and subsequent relevant full-text papers for inclusion in Scandinavian and English languages.

RESULTS

Based on three studies, the prevalence of snus use in pregnancy was up to 3.4% in the first trimester and 2.1% in the third trimester. In 12 studies, we found increased risk of several adverse effects, especially preterm delivery, stillbirth and small for gestational age associated with maternal snus use during pregnancy. Knowledge on effects of NRT during pregnancy was conflicting and inconclusive in 10 studies. We did not identify any studies on prevalence or potential health effects of snus or NRT during breastfeeding.

CONCLUSION

Few studies with updated data on the prevalence and adverse health effects of maternal use of snus and NRT during pregnancy were found. No studies during breastfeeding were identified.

Prenatal exposure to perfluoralkyl substances (PFASs) associated with respiratory tract infections but not allergy- and asthma-related health outcomes in childhood

BACKGROUND

Prenatal exposure to perfluoralkyl substances (PFASs) has been reported to be associated with immunosuppression in early childhood, but with contradictory findings related to atopic and lung diseases.

AIM

We aimed to determine if prenatal exposure to PFASs is associated with asthma or other allergic diseases or respiratory tract infections in childhood.

METHODS

Nineteen PFASs were measured in cord blood available from 641 infants in the Environment and Childhood Asthma (ECA) prospective birth cohort study. The six most abundant PFASs were perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), perfluorooctanesulfonamide (PFOSA), perfluorohexane sulfonic acid (PFHxS), perfluorononanoic acid (PFNA), and perfluoroundecanoic acid (PFUnDA). Health outcomes were assessed at two and ten years of age, and included reported obstructive airways disease (wheeze by 10 years; asthma by 2 and 10 years; reduced lung function at birth; allergic rhinitis by 10 years), atopic dermatitis (AD) by 2 and 10 years, allergic sensitization by 10 years, and episodes of common respiratory tract infections (common cold by 2 years, lower respiratory tract infections (LRTI) by 10 years). The associations between exposure and health outcomes were examined using logistic and Poisson regression.

RESULTS

The number of reported airways infections were significantly associated with cord blood concentrations of PFAS; common colds by two years with PFUnDA (β = 0.11 (0.08-0.14)) and LRTIs from 0 to 10 years of age with PFOS (β = 0.50 (0.42-0.57)), PFOA (β = 0.28 (0.22-0.35)), PFOSA (β = 0.10 (0.06-0.14)), PFNA (β = 0.09 (0.03-0.14)) and PFUnDA (β = 0.18 (0.13-0.23)) concentrations. Neither reduced lung function at birth, asthma, allergic rhinitis, AD nor allergic sensitization were significantly associated with any of the PFASs.

CONCLUSION

Although prenatal exposure to PFASs was not associated with atopic or lung manifestations by 10 years of age, several PFASs were associated with an increased number of respiratory tract infections in the first 10 years of life, suggesting immunosuppressive effects of PFASs.

Conjunctival provocation test in diagnosis of peanut allergy in children

BACKGROUND

Peanut allergy frequently causes severe allergic reactions. Diagnosis includes detection of IgE to peanuts in serum or by skin prick tests. While children may have allergic sensitization without having clinical peanut allergy, oral peanut challenge is often required for accurate diagnosis. The conjunctival provocation test is used for diagnosis and evaluation of treatment effect in inhalant allergies, but it has not been evaluated as a tool for diagnosing peanut allergy.

OBJECTIVE

To investigate whether the conjunctival provocation tests may be feasible, accurate and safe in diagnosing clinically relevant peanut allergy in patients with suspected peanut allergy.

METHODS

This cross-sectional case-control study in children with clinical or laboratory suspected peanut allergy included 102 children recruited from the regional paediatric departments and specialist practices during one year from April 2011. A peanut-tolerant control group of 28 children of similar age was recruited locally. A double-blind placebo-controlled conjunctival provocation test with peanut extract was performed in all children, while oral peanut provocation was performed as double-blind placebo-controlled challenge in children with suspected peanut allergy and as an open challenge in the control children.

RESULTS

All 81 children with a positive double-blind placebo-controlled oral food challenge (OFC) also had a positive conjunctival provocation test. None of the children with negative conjunctival provocation test had a positive OFC. The sensitivity and the specificity of the conjunctival provocation test were 0.96 and 0.83, respectively. No children had severe adverse reaction caused by the conjunctival provocation test, whereas 23 children suffered an anaphylactic reaction to the OFC.

CONCLUSION AND CLINICAL RELEVANCE

Conjunctival allergen challenge appears to be feasible, accurate and safe in diagnosing children referred for suspected peanut allergy.

Building Bridges for Innovation in Ageing: Synergies between Action Groups of the EIP on AHA

The Strategic Implementation Plan of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) proposed six Action Groups. After almost three years of activity, many achievements have been obtained through commitments or collaborative work of the Action Groups. However, they have often worked in silos and, consequently, synergies between Action Groups have been proposed to strengthen the triple win of the EIP on AHA. The paper presents the methodology and current status of the Task Force on EIP on AHA synergies. Synergies are in line with the Action Groups' new Renovated Action Plan (2016-2018) to ensure that their future objectives are coherent and fully connected. The outcomes and impact of synergies are using the Monitoring and Assessment Framework for the EIP on AHA (MAFEIP). Eight proposals for synergies have been approved by the Task Force: Five cross-cutting synergies which can be used for all current and future synergies as they consider overarching domains (appropriate polypharmacy, citizen empowerment, teaching and coaching on AHA, deployment of synergies to EU regions, Responsible Research and Innovation), and three cross-cutting synergies focussing on current Action Group activities (falls, frailty, integrated care and chronic respiratory diseases).

ARIA 2016: Care pathways implementing emerging technologies for predictive medicine in rhinitis and asthma across the life cycle

The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization workshop in 1999. The initial goals were (1) to propose a new allergic rhinitis classification, (2) to promote the concept of multi-morbidity in asthma and rhinitis and (3) to develop guidelines with all stakeholders that could be used globally for all countries and populations. ARIA—disseminated and implemented in over 70 countries globally—is now focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK [MACVIA (Contre les Maladies Chroniques pour un Vieillissement Actif)-ARIA Sentinel NetworK] uses mobile technology to develop care pathways for the management of rhinitis and asthma by a multi-disciplinary group and by patients themselves. An app (Android and iOS) is available in 20 countries and 15 languages. It uses a visual analogue scale to assess symptom control and work productivity as well as a clinical decision support system. It is associated with an inter-operable tablet for physicians and other health care professionals. The scaling up strategy uses the recommendations of the European Innovation Partnership on Active and Healthy Ageing. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health and social inequalities incurred by the disease.

Early risk factors for pubertal asthma

BACKGROUND

Early life risk factors are previously described for childhood asthma, but less is known related to asthma in adolescence. We aimed to investigate early risk factors (before 2 years) for pubertal asthma and secondarily for pubertal asthma phenotypes based upon allergic comorbidities.

METHODS

Based on data from 550 adolescents in the prospective birth cohort 'Environment and Childhood Asthma' study, subjects were categorized by recurrent bronchial obstruction (rBO) 0-2 years, asthma 2-10 years, and pubertal asthma from 10 to 16 years including incident asthma in puberty and asthma in remission from 10 to 16 years or as never rBO/asthma 0-16 years. Asthma in puberty was further classified based on the comorbidities atopic dermatitis and allergic rhinitis (AR) from 10 to 16 years. Twenty-three common asthma risk factors identified by 2 years of age, including frequency and persistence of bronchial obstruction (severity score), were analysed by weighted logistic regression for each phenotype.

RESULTS

In adjusted models, the risk of pubertal asthma increased significantly with higher severity score, parental rhinitis, being the firstborn child, and familial stress around birth. Pubertal asthma in remission was significantly associated with severity score and number of lower respiratory tract infections and inversely associated with breastfeeding beyond 4 months. Pubertal incident asthma was more common among firstborn children. All asthma phenotypes with allergic diseases were significantly associated with severity score, whereas familial perinatal stress increased the risk of asthma only. Asthma combined with AR was associated with parental asthma and being firstborn, whereas the risk of asthma with both atopic dermatitis and AR increased with higher paternal education, atopic dermatitis, being firstborn, and familial perinatal stress.

CONCLUSION AND CLINICAL RELEVANCE

Important early risk factors for pubertal asthma were early airways obstruction, parental rhinitis, being the firstborn child, and perinatal familial stress.

MACVIA-ARIA Sentinel NetworK for allergic rhinitis (MASK-rhinitis): the new generation guideline implementation

Several unmet needs have been identified in allergic rhinitis: identification of the time of onset of the pollen season, optimal control of rhinitis and comorbidities, patient stratification, multidisciplinary team for integrated care pathways, innovation in clinical trials and, above all, patient empowerment. MASK-rhinitis (MACVIA-ARIA Sentinel NetworK for allergic rhinitis) is a simple system centred around the patient which was devised to fill many of these gaps using Information and Communications Technology (ICT) tools and a clinical decision support system (CDSS) based on the most widely used guideline in allergic rhinitis and its asthma comorbidity (ARIA 2015 revision). It is one of the implementation systems of Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA). Three tools are used for the electronic monitoring of allergic diseases: a cell phone-based daily visual analogue scale (VAS) assessment of disease control, CARAT (Control of Allergic Rhinitis and Asthma Test) and e-Allergy screening (premedical system of early diagnosis of allergy and asthma based on online tools). These tools are combined with a clinical decision support system (CDSS) and are available in many languages. An e-CRF and an e-learning tool complete MASK. MASK is flexible and other tools can be added. It appears to be an advanced, global and integrated ICT answer for many unmet needs in allergic diseases which will improve policies and standards.

Increased bronchial parasympathetic tone in elite cross-country and biathlon skiers: a randomised crossover study

BACKGROUND

Increased parasympathetic activity in endurance-trained athletes has been reported by heart rate variability and pupillometry. Our primary objective was to assess parasympathetic activity and tone in the lower respiratory tract by investigating the effect of cholinergic antagonism by inhaled ipratropium bromide compared to the β2-receptor stimulating effect of inhaled salbutamol in elite cross-country and biathlon skiers. We also examined the medications' relationship to cholinergic sensitivity as measured by bronchial responsiveness to methacholine (PD20met).

METHODS

In a randomised crossover study, 20 cross-country and two biathlon skiers (14♂/8♀) aged 20-37 years from the Norwegian national teams measured reversibility to inhaled ipratropium bromide and inhaled salbutamol and PD20met on three separate days. A positive reversibility test was defined as an increase in forced expiratory volume in 1 s (FEV1) of ≥12%. Spirometry was performed before and 45 and 15 min after inhaled ipratropium bromide and inhaled salbutamol, respectively. Bronchodilating medication was withheld according to the European Respiratory Society (ERS) guidelines. Correlations were assessed by Pearson's correlation coefficient (r).

RESULTS

Five athletes had significant reversibility after inhaled ipratropium bromide, and none after inhaled salbutamol. Twelve athletes (54.5%) had PD20met <8 μmol (1.57 mg). PD20met correlated negatively with ▵FEV1 after inhaled ipratropium bromide (r=-0.85, p<0.0001), but not after inhaled salbutamol (r=-0.308, p=0.16).

CONCLUSIONS

In elite skiers, cholinergic sensitivity (PD20met) had a highly significant inverse correlation to the cholinergic antagonism of inhaled ipratropium bromide, but not at all to the bronchodilating inhaled salbutamol. This markedly increased bronchial parasympathetic tone may represent an important cholinergic role in the development of skier's asthma.

Can early skin care normalise dry skin and possibly prevent atopic eczema? A pilot study in young infants

BACKGROUND

Atopic eczema (AE) affects approximately 20% of children in Northern countries. Onset during early infancy is common and is characterised by altered skin barrier, increased water loss and defective lipid layer. Restoration of skin barrier by emollients and/or oil baths is an important part of AE treatment, but its role in preventing xerosis and AE is unknown. The present pilot study aimed to assess if xerosis, and possibly AE, could be reduced at six months of age by early introduction of frequent oil baths/facial fat cream in infants with dry skin.

METHODS

A controlled intervention pilot study included 56 six-week-old infants with xerosis, but not AE. Skin quality score ranging from 0 (normal skin) to 4 (probable AE), was assessed at inclusion, three and six months of age, with skin quality at six months as main outcome. One well baby clinic was recruited for intervention, frequent skin care (oil bath (0.5 dl) and facial fat cream, five well baby clinics recruited for observation only.

RESULTS

The intervention group (n=24) had more often normal skin (75%) at six months than the observation group (37.5%) (p<0.001), and less often probable AE (4.0 vs. 19.0%, respectively, ns). Oil baths were performed regularly, 2-4 up to 5-7 times/week in the intervention group, vs. fewer oil baths with sparse volume of oil in the observation group. No adverse reactions were reported.

CONCLUSION

Regular oil baths in infants seem to reduce xerosis and may possibly reduce atopic eczema.

Food allergens in mattress dust in Norwegian homes - a potentially important source of allergen exposure

BACKGROUND

Sensitization to food allergens and food allergic reactions are mostly caused by ingesting the allergen, but can also occur from exposure via the respiratory tract or the skin. Little is known about exposure to food allergens in the home environment.

OBJECTIVE

The objective of this study was firstly to describe the frequency of detection of allergens from fish, egg, milk, and peanut in mattress dust collected from homes of 13-year-old adolescents and secondly to identify home characteristics associated with the presence of food allergen contamination in dust.

METHODS

Food allergens were measured by dot blot analysis in mattress dust from 143 homes in Oslo, Norway. We analysed associations between home characteristics (collected by parental questionnaires and study technicians) and food allergens by multivariate regression models.

RESULTS

Fish allergen was detected in 46%, peanut in 41%, milk in 39%, and egg allergen in 22% of the mattress dust samples; only three samples contained none of these allergens. All four food allergens were more frequently detected in mattresses in small dwellings (< 100 m(2)) than larger dwellings (≥ 130 m(2)); 63-71% of the small dwellings (n = 24) had milk, peanut, and fish allergens in the samples compared with 33-44% of the larger dwellings (n = 95). Milk, peanut, and egg allergens were more frequently detected in homes with bedroom and kitchen on the same floor as compared with different floors, with odds ratios of 2.5 (95% confidence interval (CI): 1.1, 5.6) for milk, 2.4 (95% CI: 1.0, 6.1) for peanut, and 3.1 (95% CI: 1.3, 7.5) for egg allergens.

CONCLUSIONS AND CLINICAL RELEVANCE

Food allergens occurred frequently in beds in Norwegian homes, with dwelling size and proximity of kitchen and bedroom as the most important determinants. Due to the amount of time children spent in the bedroom, mattress dust may be an important source of exposure to food allergens.

Integrated care pathways for airway diseases (AIRWAYS-ICPs)

The objective of Integrated Care Pathways for Airway Diseases (AIRWAYS-ICPs) is to launch a collaboration to develop multi-sectoral care pathways for chronic respiratory diseases in European countries and regions. AIRWAYS-ICPs has strategic relevance to the European Union Health Strategy and will add value to existing public health knowledge by: 1) proposing a common framework of care pathways for chronic respiratory diseases, which will facilitate comparability and trans-national initiatives; 2) informing cost-effective policy development, strengthening in particular those on smoking and environmental exposure; 3) aiding risk stratification in chronic disease patients, using a common strategy; 4) having a significant impact on the health of citizens in the short term (reduction of morbidity, improvement of education in children and of work in adults) and in the long-term (healthy ageing); 5) proposing a common simulation tool to assist physicians; and 6) ultimately reducing the healthcare burden (emergency visits, avoidable hospitalisations, disability and costs) while improving quality of life. In the longer term, the incidence of disease may be reduced by innovative prevention strategies. AIRWAYSICPs was initiated by Area 5 of the Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing. All stakeholders are involved (health and social care, patients, and policy makers).

Allergic Rhinitis and its Impact on Asthma (ARIA): achievements in 10 years and future needs

Allergic rhinitis (AR) and asthma represent global health problems for all age groups. Asthma and rhinitis frequently coexist in the same subjects. Allergic Rhinitis and its Impact on Asthma (ARIA) was initiated during a World Health Organization workshop in 1999 (published in 2001). ARIA has reclassified AR as mild/moderate-severe and intermittent/persistent. This classification closely reflects patients' needs and underlines the close relationship between rhinitis and asthma. Patients, clinicians, and other health care professionals are confronted with various treatment choices for the management of AR. This contributes to considerable variation in clinical practice, and worldwide, patients, clinicians, and other health care professionals are faced with uncertainty about the relative merits and downsides of the various treatment options. In its 2010 Revision, ARIA developed clinical practice guidelines for the management of AR and asthma comorbidities based on the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system. ARIA is disseminated and implemented in more than 50 countries of the world. Ten years after the publication of the ARIA World Health Organization workshop report, it is important to make a summary of its achievements and identify the still unmet clinical, research, and implementation needs to strengthen the 2011 European Union Priority on allergy and asthma in children.

Severe chronic allergic (and related) diseases: a uniform approach--a MeDALL--GA2LEN--ARIA position paper

Concepts of disease severity, activity, control and responsiveness to treatment are linked but different. Severity refers to the loss of function of the organs induced by the disease process or to the occurrence of severe acute exacerbations. Severity may vary over time and needs regular follow-up. Control is the degree to which therapy goals are currently met. These concepts have evolved over time for asthma in guidelines, task forces or consensus meetings. The aim of this paper is to generalize the approach of the uniform definition of severe asthma presented to WHO for chronic allergic and associated diseases (rhinitis, chronic rhinosinusitis, chronic urticaria and atopic dermatitis) in order to have a uniform definition of severity, control and risk, usable in most situations. It is based on the appropriate diagnosis, availability and accessibility of treatments, treatment responsiveness and associated factors such as comorbidities and risk factors. This uniform definition will allow a better definition of the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes, education and the discovery of novel therapies.

Practical guide to skin prick tests in allergy to aeroallergens

This pocket guide is the result of a consensus reached between members of the Global Allergy and Asthma European Network (GA(2) LEN) and Allergic Rhinitis and its Impact on Asthma (ARIA). The aim of the current pocket guide is to offer a comprehensive set of recommendations on the use of skin prick tests in allergic rhinitis-conjunctivitis and asthma in daily practice. This pocket guide is meant to give simple answers to the most frequent questions raised by practitioners in Europe, including 'practicing allergists', general practitioners and any other physicians with special interest in the management of allergic diseases. It is not a long or detailed scientific review of the topic. However, the recommendations in this pocket guide were compiled following an in-depth review of existing guidelines and publications, including the 1993 European Academy of Allergy and Clinical Immunology position paper, the 2001 ARIA document and the ARIA update 2008 (prepared in collaboration with GA(2) LEN). The recommendations cover skin test methodology and interpretation, allergen extracts to be used, as well as indications in a variety of settings including paediatrics and developing countries.

How to design and evaluate randomized controlled trials in immunotherapy for allergic rhinitis: an ARIA-GA(2) LEN statement

Specific immunotherapy (SIT) is one of the treatments for allergic rhinitis. However, for allergists, nonspecialists, regulators, payers, and patients, there remain gaps in understanding the evaluation of randomized controlled trials (RCTs). Although treating the same diseases, RCTs in SIT and pharmacotherapy should be considered separately for several reasons, as developed in this study. These include the severity and persistence of allergic rhinitis in the patients enrolled in the study, the problem of the placebo, allergen exposure (in particular pollen and mite), the analysis and reporting of the study, the level of symptoms of placebo-treated patients, the clinical relevance of the efficacy of SIT, the need for a validated combined symptom-medication score, the differences between children and adults and pharmacoeconomic analyses. This statement reviews issues raised by the interpretation of RCTs in sublingual immunotherapy. It is not possible to directly extrapolate the rules or parameters used in medication RCTs to SIT. It also provides some suggestions for the research that will be needed. Interestingly, some of the research questions can be approached with the available data obtained from large RCTs.

MeDALL (Mechanisms of the Development of ALLergy): an integrated approach from phenotypes to systems medicine

The origin of the epidemic of IgE-associated (allergic) diseases is unclear. MeDALL (Mechanisms of the Development of ALLergy), an FP7 European Union project (No. 264357), aims to generate novel knowledge on the mechanisms of initiation of allergy and to propose early diagnosis, prevention, and targets for therapy. A novel phenotype definition and an integrative translational approach are needed to understand how a network of molecular and environmental factors can lead to complex allergic diseases. A novel, stepwise, large-scale, and integrative approach will be led by a network of complementary experts in allergy, epidemiology, allergen biochemistry, immunology, molecular biology, epigenetics, functional genomics, bioinformatics, computational and systems biology. The following steps are proposed: (i) Identification of 'classical' and 'novel' phenotypes in existing birth cohorts; (ii) Building discovery of the relevant mechanisms in IgE-associated allergic diseases in existing longitudinal birth cohorts and Karelian children; (iii) Validation and redefinition of classical and novel phenotypes of IgE-associated allergic diseases; and (iv) Translational integration of systems biology outcomes into health care, including societal aspects. MeDALL will lead to: (i) A better understanding of allergic phenotypes, thus expanding current knowledge of the genomic and environmental determinants of allergic diseases in an integrative way; (ii) Novel diagnostic tools for the early diagnosis of allergy, targets for the development of novel treatment modalities, and prevention of allergic diseases; (iii) Improving the health of European citizens as well as increasing the competitiveness and boosting the innovative capacity of Europe, while addressing global health issues and ethical issues.

Viruses and bacteria in acute asthma exacerbations--a GA² LEN-DARE systematic review

To cite this article: Papadopoulos NG, Christodoulou I, Rohde G, Agache I, Almqvist C, Bruno A, Bonini S, Bont L, Bossios A, Bousquet J, Braido F, Brusselle G, Canonica GW, Carlsen KH, Chanez P, Fokkens WJ, Garcia‐Garcia M, Gjomarkaj M, Haahtela T, Holgate ST, Johnston SL, Konstantinou G, Kowalski M, Lewandowska‐Polak A, Lødrup‐Carlsen K, Mäkelä M, Malkusova I, Mullol J, Nieto A, Eller E, Ozdemir C, Panzner P, Popov T, Psarras S, Roumpedaki E, Rukhadze M, Stipic‐Markovic A, Todo Bom A, Toskala E, van Cauwenberge P, van Drunen C, Watelet JB, Xatzipsalti M, Xepapadaki P, Zuberbier T. Viruses and bacteria in acute asthma exacerbations – A GA²LEN‐DARE systematic review. Allergy 2011; 66: 458–468.

Abstract

A major part of the burden of asthma is caused by acute exacerbations. Exacerbations have been strongly and consistently associated with respiratory infections. Respiratory viruses and bacteria are therefore possible treatment targets. To have a reasonable estimate of the burden of disease induced by such infectious agents on asthmatic patients, it is necessary to understand their nature and be able to identify them in clinical samples by employing accurate and sensitive methodologies. This systematic review summarizes current knowledge and developments in infection epidemiology of acute asthma in children and adults, describing the known impact for each individual agent and highlighting knowledge gaps. Among infectious agents, human rhinoviruses are the most prevalent in regard to asthma exacerbations. The newly identified type‐C rhinoviruses may prove to be particularly relevant. Respiratory syncytial virus and metapneumovirus are important in infants, while influenza viruses seem to induce severe exacerbations mostly in adults. Other agents are relatively less or not clearly associated. Mycoplasma and Chlamydophila pneumoniae seem to be involved more with asthma persistence rather than with disease exacerbations. Recent data suggest that common bacteria may also be involved, but this should be confirmed. Although current information is considerable, improvements in detection methodologies, as well as the wide variation in respect to location, time and populations, underline the need for additional studies that should also take into account interacting factors.

The breathless adolescent asthmatic athlete

This article concerns physical activity and sports in asthmatic adolescents. Exercise-induced asthma (EIA) is found in 8-10% of the normal child population and in ∼35% of children with current asthma, as reported in a population-based birth cohort study. The mechanisms of EIA are related to markedly increased ventilation during exercise, which causes increased heat and water loss through respiration, leading to bronchial constriction. In athletes and especially in endurance athletes, the repeated daily physical activity during training will, over time, cause epithelial damage and increase inflammation in the respiratory mucosa. With increased exposure to environmental agents, such as as cold air in skiers and chlorine compounds in swimmers, the athlete may contract symptoms and signs of asthma and bronchial hyperresponsiveness, either worsening existing asthma or causing symptoms in a previous healthy adolescent athlete. There are several causes of breathlessness in adolescents, including EIA, vocal cord dysfunction, poor physical fitness and others, which are important to consider in the diagnostic procedure. The asthmatic athlete should follow the same guidelines for treating their asthma as an ordinary asthmatic patient, with careful consideration of the special diagnostic rules given for the use of asthma drugs in sports, especially for inhaled β(2)-agonists.

Reduced basal salivary cortisol in children with asthma and allergic rhinitis

AIM

Reduced basal cortisol is reported in allergic disease. We investigated if basal salivary cortisol levels were reduced in children with asthma or allergic rhinitis, controlling for inhaled corticosteroids (ICS) use.

METHODS

Morning and evening saliva of asthmatic children aged 7-12 years (n = 50) and that of controls (n = 52) were sampled. A total of 19 asthmatics and four controls had allergic rhinitis. Healthy children were controls without rhinitis. Of all, 14 asthmatic children used low, and 12 used moderate or high doses of ICS. Cortisol was analysed by radioimmunoassay.

RESULTS

Morning salivary cortisol median (95% CI) was lower in asthmatics (8.7 (7.1, 9.7)) compared with that in controls (10.4 (9.6, 11.8); p = 0.006), which was similar for evening cortisol levels. Regression analyses demonstrated that asthmatics using moderate or high doses of ICS had reduced morning salivary cortisol adjusted (for age and gender) odds ratio (aOR) (95% CI) (0.54 (0.37, 0.80); p = 0.002) and reduced evening cortisol aOR (0.09 (0.01, 0.6); p = 0.02) compared with that in healthy children. Asthmatics with rhinitis on no or low doses of ICS had reduced morning cortisol aOR (0.73 (0.56, 0.96); p = 0.02) compared with that in healthy children.

CONCLUSION

Asthmatic children on moderate or high doses of inhaled corticosteroids had reduced salivary cortisol, but co-morbidity of asthma and rhinitis was also associated with reduced cortisol levels.

Assessment of problematic severe asthma in children

Assessment of problematic severe asthma in children should be performed in a step-wise manner to ensure an optimal approach. A four-step assessment scheme is proposed. First, a full diagnostic work-up is performed to exclude other diseases which mimic asthma. Secondly, a multi-disciplinary assessment is performed to identify issues that may need attention, including comorbidities. Thirdly, the pattern of inflammation is assessed, and finally steroid responsiveness is documented. Based upon these four steps an optimal individualised treatment plan is developed. In this article the many gaps in our current knowledge in all these steps are highlighted, and recommendations for current clinical practice and future research are made. The lack of good data and the heterogeneity of problematic severe asthma still limit our ability to optimise the management on an individual basis in this small, but challenging group of patients.

Problematic severe asthma in children, not one problem but many: a GA2LEN initiative

Although most children with asthma are easy to treat with low doses of safe medications, many remain symptomatic despite every therapeutic effort. The nomenclature regarding this group is confusing, and studies are difficult to compare due to the proliferation of terms describing poorly defined clinical entities. In this review of severe asthma in children, the term problematic severe asthma is used to describe children with any combination of chronic symptoms, acute severe exacerbations and persistent airflow limitation despite the prescription of multiple therapies. The approach to problematic severe asthma may vary with the age of the child, but, in general, three steps need to be taken in order to separate difficult-to-treat from severe therapy-resistant asthma. First, confirmation that the problem is really due to asthma requires a complete diagnostic re-evaluation. Secondly, the paediatrician needs to systematically exclude comorbidity, as well as personal or family psychosocial disorders. The third step is to re-evaluate medication adherence, inhaler technique and the child's environment. There is a clear need for a common international approach, since there is currently no uniform agreement regarding how best to approach children with problematic severe asthma. An essential first step is proper attention to basic care.

Can childhood asthma be predicted at birth?

BACKGROUND

Early life appears optimal for prevention of asthma, but interventions require a relevant target population, to date not clearly identified at birth.

OBJECTIVE

We therefore aimed to identify the predicting capacity of factors known around birth for asthma and rhinitis at 10 years.

METHODS

The included 614 healthy term babies with lung function measured at birth in the 1992/1993 Environment and Childhood Asthma study in Oslo attended a 10-year follow-up visit including a structured interview and skin prick test (SPT) for allergies. The logistic regression analyses included 37 general variables from an extensive birth questionnaire; lung function; cord blood total immunoglobulin E and soluble CD14. A history of asthma, current asthma, history of rhinitis and 'healthy' (no history of asthma, rhinitis and negative SPT) was predicted on a group level and individual predicted probabilities were calculated.

RESULTS

The predictability of the models [area under the curve (95% confidence intervals)] was 0.74 (0.69, 0.79), 0.72 (0.64, 0.78), 0.69 (0.54, 0.72) and 0.67 (0.62, 0.71) for a history of asthma, current asthma, rhinitis and 'healthy', respectively. The best model predicted a history of asthma correctly in 93/124 (75%), and incorrectly in 176/490 (36%) children without asthma. The positive predictive values for all outcomes were low (19-61), the highest predicting healthy.

CONCLUSION

Although at best 75% of children with a history of asthma could be predicted at birth, an intervention applied to our predicted high-risk children would be started more often in children without than with future disease. Parental allergic disease alone appears insufficient to identify high-risk populations in future studies of asthma and allergic disease.

Development and implementation of guidelines in allergic rhinitis – an ARIA-GA2LEN paper

The links between asthma and rhinitis are well characterized. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines stress the importance of these links and provide guidance for their prevention and treatment. Despite effective treatments being available, too few patients receive appropriate medical care for both diseases. Most patients with rhinitis and asthma consult primary care physicians and therefore these physicians are encouraged to understand and use ARIA guidelines. Patients should also be informed about these guidelines to raise their awareness of optimal care and increase control of the two related diseases. To apply these guidelines, clinicians and patients need to understand how and why the recommendations were made. The goal of the ARIA guidelines is to provide recommendations about the best management options for most patients in most situations. These recommendations should be based on the best available evidence. Making recommendations requires the assessment of the quality of available evidence, deciding on the balance between benefits and downsides, consideration of patients’ values and preferences, and, if applicable, resource implications. Guidelines must be updated as new management options become available or important new evidence emerges. Transparent reporting of guidelines facilitates understanding and acceptance, but implementation strategies need to be improved.

Asthma prediction in school children; the value of combined IgE-antibodies and obstructive airways disease severity score

BACKGROUND

Allergic sensitisation increases the risk for asthma development. In this prospective birth cohort (Environment and Childhood Asthma) study, we hypothesized that combining quantitative measures of IgE antibodies (Sigma-IgE) and Severity score of obstructive airways disease (OAD) at 2 years of age (Severity score) is superior to predict current asthma (CA) at 10 years than either measure alone. Secondarily, we assessed if gender modified the prediction of CA.

METHODS

A follow-up study at 10 years of age was performed in 371 2-year-old children with recurrent (n = 219) or no (n = 152) bronchial obstruction with available serum analysed for Sigma-IgE to common food and inhalant allergens through a panel test, Phadiatop Infant) (Phadia, Uppsala, Sweden). Clinical variables included allergic sensitisation and exercise testing to characterise children with CA vs not CA at 10 years and the Severity score (0-12, 0 indicating no OAD) was used to assess risk modification.

RESULTS

Severity score alone explained 24% (Nagelkerke R(2) = 0.24) of the variation in CA, whereas Sigma-IgE explained only 6% (R(2) = 0.06). Combining the two increased the explanatory capacity to R(2) = 0.30. Gender interacted significantly with Sigma-IgE; whereas Severity score predicted CA in both genders, the predictive capacity of Sigma-IgE for CA at 10 years was significant in boys only.

CONCLUSION

Combining Sigma-IgE to inhalant allergens and Severity score at 2 years was superior to predict asthma at 10 years than either alone. Severity score predicted CA in both genders, whereas Sigma-IgE significantly predicted CA in boys only.

Can one single test protocol for provoking exercise-induced bronchoconstriction also be used for assessing aerobic capacity?

INTRODUCTION

Several different exercise protocols are used to assess exercise-induced bronchoconstriction (EIB), and to measure peak oxygen uptake (VO(2 peak)) and peak minute ventilation (VE(peak)).

OBJECTIVE

The aim of this study was to evaluate if one single test protocol for assessing EIB can also be used to determine aerobic capacity measured by VO(2 peak) and VE(peak).

METHODS

In a randomised cross-over design, 40 healthy subjects (female symbol/male symbol = 17/23) aged 14-40 years performed two exercise tests on a treadmill. Twenty subjects (female symbol/male symbol = 7/13) performed the two exercise tests at a treadmill inclination of 10.5%; the remaining 20 subjects (female symbol/male symbol = 10/10) performed at an inclination of 5.3%. A common stepwise protocol with 20 min of warming up was compared to an EIB test protocol of an 8-min treadmill run without warming up, with a workload corresponding to 95% of maximum heart rate during the last 4 min.

RESULTS

VO(2 peak) did not differ significantly between the two test protocols at 10.5% inclination: 63.3 mL/kg min(-1)(59.3, 67.4) [mean (95% confidence intervals)] and 63.9 mL/kg min(-1) (60.0, 68.0), respectively, or at 5.3% inclination: 56.0 mL/kg min(-1) (52.1, 60.0) and 56.1 mL/kg min(-1) (51.9, 60.2), respectively. Also, VE(peak) did not differ between the protocols 158 (144, 173) vs 161 L/min (145, 176) at 10.5% inclination and 123 (114, 132) vs 127 L/min (116, 138) at 5.3% inclination, with the EIB protocol and the stepwise protocol, respectively.

CONCLUSION

VO(2 peak) and VE(peak) did not differ between the two test protocols, and one single standardised EIB test may thus be used both for both provoking EIB and assessing VO(2 peak).

Gender differences in indoor allergen exposure and association with current rhinitis

BACKGROUND

Differences between boys and girls in allergic manifestations are well known, and this difference is possibly not attributed to physiological differences alone.

OBJECTIVE

We, therefore, investigated whether boys and girls could be exposed to different allergen levels at home and whether indoor allergen levels could be differently associated with rhinitis in boys and girls at 10 years of age.

METHODS

Cat, dog and house dust mite (HDM) allergen levels in mattress dust and interview data regarding current allergic disease were available for 797 10-year-old children (360 girls) in The Environment and Childhood Asthma Study in Oslo.

RESULTS

Girls had higher concentrations of cat and dog allergens in their mattresses compared with boys, also in homes without cats [geometric mean 95% confidence intervals (95% CI): 0.37 (0.31, 0.44) for girls and 0.26 (0.23, 0.30) microg cat allergen/g dust for boys, P=0.002], and without dogs [girls: 0.74 (0.63, 0.86) and boys: 0.55 (0.48, 0.62) microg dog allergen/g dust, P=0.003]. No difference was observed for HDM allergen (Der p 1) levels. Of the 190 (23.8%) children reporting current rhinitis, 144 (75.8%) were sensitized to at least one allergen. The adjusted odds ratio for current rhinitis increased with 1.20 (95% CI: 1.01, 1.42) per 1 microg/g dust increase in Der p 1 for girls (P=0.037), but not for boys (P=0.91).

CONCLUSION

Girls had higher levels of cat and dog allergens in mattress dust compared with boys, whereas no difference was observed for Der p 1 allergen. Nevertheless, only increasing levels of Der p 1 and not cat and dog allergens significantly increased the risk of current rhinitis in girls, whereas no significant association was observed for boys.

Childhood asthma and early life exposure to indoor allergens, endotoxin and beta(1,3)-glucans

BACKGROUND

Divergent results have been reported regarding early life exposure to indoor environmental agents and the risk of asthma and allergic sensitization later in life.

OBJECTIVE

To assess whether early exposure to indoor allergens, beta(1,3)-glucans and endotoxin modifies the risk of allergic diseases at 10 years of age.

METHODS

The concentrations of mite, cat and dog allergens, endotoxin and beta(1,3)-glucans were determined in dust from the homes of 260 two-year-old children with lung function measured at birth (tidal flow volume loops) in the Environment and Childhood Asthma study in Oslo. At 10 years, the health status was assessed in a follow-up study including a structured interview of the parents and an extended clinical examination.

RESULTS

Cat and dog keeping at 2 years of age was reported in 6.5% and 5.5% of the families, respectively. Mite allergens were detected in only 4/260 dust samples. The adjusted odds ratio for asthma at age 10 was 1.20 (95% confidence interval: 1.01-1.43) and 1.22 (1.02-1.46) for bronchial hyperresponsiveness (BHR) per 10 microg/g dust increase in cat allergen exposure at 2 years of age. No association was seen with allergic sensitization. Moreover, endotoxin and beta(1,3)-glucan exposure did not modify the risk of asthma or allergic sensitization. None of the measured environmental factors were associated with lung function at 10 years of age or a relative change in lung function from birth.

CONCLUSION

In a community with a low prevalence of pet keeping and low mite allergen levels, exposure to cat allergens early in life increased the risk of late childhood asthma and BHR, but not the risk of allergic sensitization. No risk modification was seen for dog allergens, endotoxin and beta(1,3)-glucans.

Do allergic families avoid keeping furry pets?

Studies addressing the relationship between pet keeping and development of asthma and allergies may be influenced by pet avoidance in families with a history of allergic disease. Following a cohort of 1019 children in Oslo till 10 years of age, we studied the association of pet keeping with socio-economic factors and allergic disease in the family. A family history of asthma and rhinoconjunctivitis was not significantly associated with pet ownership at birth or with pet removal by 10 years. Acquiring cats and dogs was less likely if the child had allergic rhinoconjunctivitis, whereas no association was seen with asthma (in any family member). Single parenthood increased the likelihood of acquiring a cat, smoking parents more often had cats or dogs, and having older siblings was associated with keeping dogs and other furry pets. Among 319 families reporting pet avoidance, 70% never had pets, 8% had given up pets, and 22% avoided a particular type of pet only. Twenty-four per cent of the parents failed to retrospectively report pet keeping during the child's first year of life. Overall, allergic rhinitis, but not asthma was associated with actual pet avoidance, whereas the strongest predictors for keeping pets were found to be socio-economic factors.

PRACTICAL IMPLICATIONS

Allergic disease in a child most often does not lead to the removal of the family's furry pet. Pet avoidance is associated with allergic symptoms, but not asthma. Socio-economic factors like parental education, single parenthood and smoking affects the families' decisions on pet keeping, including the type of pets the families will avoid or acquire. The large recall error demonstrated points to the need for prospective data regarding pet keeping.

Establishing a standardized quality management system for the European Health Network GA2LEN

BACKGROUND

Quality management is increasingly important in clinical practice. The Global Allergy and Asthma European Network (GA(2)LEN) is a network of clinical and scientific excellence with originally 25 allergy centres in 16 European countries, a scientific society (European Academy of Allergology and Clinical Immunology), and a patient organization (European Federation of Allergy and Airways Diseases Patients' Associations). Although some allergy centres adhere to internal quality criteria, the implementation of a standardized quality management system for allergy centres across Europe was lacking.

OBJECTIVES

To implement standardized quality criteria among allergy centres organized within GA(2)LEN and thus ensure equal standards of diagnosis and care as well as to establish a culture of continuous quality improvement.

METHODS

Quality criteria covering, e.g., diagnostic and therapeutic procedures, and emergency preparedness to assure patient safety were developed and agreed upon by all 25 participating centres. To assure implementation of quality criteria, centres were audited to check quality indicators and document deviations. A follow-up survey was used to assess the usefulness of the project.

RESULTS

Deviations were documented mainly in the areas of emergency care/patient safety (27.3% lacked regular emergency training of doctors and nurses; 22.7% inadequate emergency intervention equipment; 22.7% lacked critical incidence reporting/root cause analyses) and handling of extracts/pharmaceuticals (31.8% lacked temperature logs of fridges; 4.5% inadequate check of expiration dates). Quality improvement was initiated as shown by findings of re-audits. Usefulness of the project was rated high.

CONCLUSION

The establishment of a quality management system with joint standards of care and harmonized procedures can be achieved in an international health network and ensures quality of care.

Prioritised research agenda for prevention and control of chronic respiratory diseases

The 2008-2013 World Health Organization (WHO) action plan on noncommunicable diseases (NCDs) includes chronic respiratory diseases as one of its four priorities. Major chronic respiratory diseases (CRDs) include asthma and rhinitis, chronic obstructive pulmonary disease, occupational lung diseases, sleep-disordered breathing, pulmonary hypertension, bronchiectiasis and pulmonary interstitial diseases. A billion people suffer from chronic respiratory diseases, the majority being in developing countries. CRDs have major adverse effects on the life and disability of patients. Effective intervention plans can prevent and control CRDs, thus reducing morbidity and mortality. A prioritised research agenda should encapsulate all of these considerations in the frame of the global fight against NCDs. This requires both CRD-targeted interventions and transverse NCD programmes which include CRDs, with emphasis on health promotion and disease prevention.

Identifying problematic severe asthma in the individual child--does lung function matter?

AIM

Measures of lung function (usually FEV(1) <80% predicted) are used to classify asthma severity in both adults and children, despite evidence that lung function impairment is less pronounced in the paediatric asthma population. The present study assesses the relevance of lung function measurements as discriminators of severe childhood asthma.

METHODS

Fifty-one school-aged children with problematic severe asthma, 37 mild-to-moderate asthmatics and 29 healthy controls underwent a comprehensive clinical work-up. Problematic severe asthma was defined in patients exhibiting poor asthma control despite high-dose inhaled corticosteroid treatment and at least one other asthma controller drug. Mild-to-moderate asthmatic children used low-dose inhaled steroids and reported minimal asthma symptoms.

RESULTS

Baseline FEV(1) values were significantly reduced in children with problematic severe asthma, yet FEV(1) <80% predicted showed a low sensitivity (41%) for discriminating severe vs. mild-to-moderate asthma. Receiver-operated characteristic analysis estimated the optimal cut-off of FEV(1) to be 90% predicted in this population (sensitivity 61%, specificity 83%). Baseline FEV(1)/FVC and FEF(25-75) values were not superior to FEV(1) in discriminating problematic severe asthma, and neither exhaled nitric oxide levels nor bronchial hyperresponsiveness differentiated between the two asthmatic study populations.

CONCLUSION

Spirometric measurements are insensitive discriminators of problematic severe asthma in childhood.

Diagnostic value of exhaled nitric oxide in childhood asthma and allergy

Fractional exhaled nitric oxide (FE(NO) ) has been proposed as a diagnostic test of asthma. We aimed to investigate in a population based birth cohort of children the usefulness of FE(NO) as a diagnostic tool. The 10-yr follow up of the Environment and Childhood Asthma Study in Oslo included 616 children representative of the prospective birth cohort. Both FE(NO) (single breath technique) and skin prick test (SPT) were measured in 331, limited at the time by equipment availability. Structural parental interview, spirometry, methacholine challenge and exercise test were performed. FE(NO) was significantly elevated in children with current asthma (geometric mean 9.6 (95% confidence interval (CI) (6.9, 13.4) p.p.b.) compared with healthy children (5.8 (5.4, 6.3) p.p.b.; p < 0.001). FE(NO) was highest among children with current allergic asthma (asthma and positive SPT) (14.0 (8.9, 22.1) p.p.b.), whereas children with non-allergic asthma (6.1 (4.0, 9.2) p.p.b.) had comparable FE(NO) levels to healthy children (p = 0.99). Allergic sensitization was most closely associated with FE(NO) . A FE(NO) cut-off value of 20.4 p.p.b. had a high specificity (0.97), but a low sensitivity (0.41) and a Positive Likelihood Ratio of 16.1 for current allergic asthma. In the present childhood population-based study, high FE(NO) levels were closely associated with current allergic asthma and not with current asthma without allergic sensitization. Estimating the individual predictive probability of having asthma by use of FE(NO,) improves the diagnostic utility of the test.

Asthma symptoms in rural living Tanzanian children; prevalence and the relation to aerobic fitness and body fat

OBJECTIVE

To determine the prevalence of asthma symptoms in children from a rural district in North-Tanzania, and their relationship to aerobic fitness and body fat.

METHODS

In Manyara region in Tanzania, children (aged 9-10 years) were randomly selected to participate in the present cross-sectional study. Hundred and seventy two participants completed a video questionnaire showing the symptoms and signs of asthma. Lung function was measured by maximum forced expiratory flow-volume curves. Aerobic fitness was estimated from a standardized indirect maximal cycle ergometer test and sum of three skinfolds reflected body fat.

RESULTS

Twenty four per cent reported asthma symptoms last year. Severe wheezing attacks last year were reported in 5% of the participants. Thirty seven per cent of the participants were underweight. Underweight children had significantly lower (P < 0.02) lung function (per cent of predicted). Lower body fat was associated with higher occurrence of asthma symptoms (odds ratio and 95% CI; 0.45 (0.22-0.95; P = 0.04). Aerobic fitness was not associated with asthma symptoms.

CONCLUSIONS

More than every fifth 9-10 year old child from a rural district in North-Tanzania reported asthma symptoms. Lower body fat was associated with higher occurrence of asthma symptoms, but aerobic fitness was not associated with asthma symptoms.

GA2LEN (Global Allergy and Asthma European Network) addresses the allergy and asthma 'epidemic'

Allergic diseases represent a major health problem in Europe. They are increasing in prevalence, severity and costs. The Global Allergy and Asthma European Network (GA(2)LEN), a Sixth EU Framework Program for Research and Technological Development (FP6) Network of Excellence, was created in 2005 as a vehicle to ensure excellence in research bringing together research and clinical institutions to combat fragmentation in the European research area and to tackle allergy in its globality. The Global Allergy and Asthma European Network has benefited greatly from the voluntary efforts of researchers who are strongly committed to this model of pan-European collaboration. The network was organized in order to increase networking for scientific projects in allergy and asthma around Europe and to make GA(2)LEN the world leader in the field. Besides these activities, research has also been carried out and the first papers are being published. Achievements of the Global Allergy and Asthma European Network can be grouped as follows: (i) those for a durable infrastructure built up during the project phase, (ii) those which are project-related and based on these novel infrastructures, and (iii) the development and implementation of guidelines. The major achievements of GA(2)LEN are reported in this paper.

Norwegian adolescents with asthma are physical active and fit

BACKGROUND

Evidence regarding habitual physical activity levels and aerobic fitness of asthmatic compared to nonasthmatic children and adolescents is contradictory, and it is unclear if low physical activity levels can contribute to asthma development. The present study therefore aimed to determine whether adolescents with asthma have reduced physical activity levels and aerobic fitness, or increased energy intake and body fat compared to controls.

METHODS

From the environment and childhood asthma study in Oslo, 174 (13- to 14-year old) adolescents, 95 (66 boys) with and 79 (41 boys) without asthma performed maximal running on a treadmill with oxygen consumption measurement (aerobic fitness) and had the sum of four skinfolds and waist circumference recorded (body fat), followed by wearing an activity monitor and registering diet for four consecutive days. Asthma was defined by at least two of the following three criteria fulfilled: (1) dyspnoea, chest tightness and/or wheezing; (2) a doctor's diagnosis of asthma; (3) use of asthma medication. Participants with asthma used their regular medications.

RESULTS

Neither aerobic fitness, total energy expenditure nor hours in moderate to very vigorous intensity physical activity during week and weekend differed between adolescents with and without asthma. Energy intake and body fat was similar in both groups.

CONCLUSIONS

Total energy expenditure, aerobic fitness and hours in moderate to very vigorous intensity physical activity were not reduced and energy intake and body fat measured with skinfolds not increased among Norwegian adolescents with asthma.

A TLR2 polymorphism is associated with type 1 diabetes and allergic asthma

Type 1 diabetes (T1D) and allergic asthma are immune-mediated diseases. Pattern recognition receptors are proteins expressed by cells in the immune system to identify microbial pathogens and endogenous ligands. Toll-like receptors (TLRs) and CD14 are members of this family and could represent a molecular link between microbial infections and immune-mediated diseases. Diverging hypotheses regarding whether there exists a common or inverse genetic etiology behind these immune-mediated diseases have been presented. We aimed to test whether there exist common or inverse associations between polymorphisms in the pattern recognition receptors TLR2, TLR4 and CD14 and T1D and allergic asthma. Eighteen single nucleotide polymorphisms (SNPs) were genotyped in TLR2 (2), TLR4 (12) and CD14 (4) in 700 T1D children, 357 nuclear families with T1D children and 796 children from the 'Environment and Childhood Asthma' study. Allele and haplotype frequencies were analyzed in relation to diseases and in addition transmission disequilibrium test analyses were performed in the family material. Both T1D and allergic asthma were significantly associated with the TLR2 rs3804100 T allele and further associated with the haplotype including this SNP, possibly representing a susceptibility locus common for the two diseases. Neither TLR4 nor CD14 were associated with T1D or allergic asthma.

Meta-analysis of determinants for pet ownership in 12 European birth cohorts on asthma and allergies: a GA2LEN initiative

BACKGROUND

Studies on pet ownership as a risk or protective factor for asthma and allergy show inconsistent results. This may be on account of insufficient adjustment of confounding factors.

AIM

The objective of this study was to describe determinants of cat and dog ownership in European families with and without allergies.

METHODS

Within the EU-funded network of excellence GA(2)LEN, we performed meta-analyses with data from 12 ongoing European birth cohort studies on asthma and allergy. Each of the birth cohort studies enrolled between 485 and 4089 children. Pet ownership, allergic status (asthma, allergic rhinitis, eczema) of parents and siblings, parental education, access to ground floor, and number of people living at home were assessed by questionnaires.

RESULTS

Among the 25 056 families from seven European countries cats (14.9%) were more common than dogs (12.0%). Allergic family history significantly reduced the odds to own a cat (adjusted combined random-effect OR 0.91; 95% CI 0.85-0.99), or dog (0.90; 0.86-0.94). A higher parental educational level had even more pronounced effects on cat (0.84; 0.71-0.98), and dog ownership (0.61; 0.54-0.70). Elder siblings reduced the odds to own cats, but not dogs. Convenient ground access significantly increased the odds, whereas crowding at home was not associated with cat or dog ownership.

CONCLUSIONS

The chances to own a cat or dog were significantly reduced in allergic families, in parents with a higher educational level, and in homes without convenient ground access. In addition to parental allergies, social and housing factors should be considered as potential confounders in studies on pet exposure and allergic diseases.

Severe asthma in childhood: assessed in 10 year olds in a birth cohort study

BACKGROUND

Limited information is available regarding the prevalence of severe asthma in children. The present study aimed at investigating the prevalence of severe asthma in an urban child population; secondarily evaluating the applicability of the chosen definition by clinical characteristics.

METHODS

Children enrolled in the prospective birth cohort; the Environment and Childhood Asthma Study in Oslo; were reinvestigated at the age of 10 years (n = 1019). A representative population based cohort of 616 children [mean age 10.9 (SD 0.9) years] with lung function measurements at birth was used for prevalence estimates, whereas all 1019 children (154 with current asthma) attending the 10-year follow-up were included for verification of the definition of severe asthma. Clinical investigations included spirometry, tests of bronchial hyperresponsiveness, skin prick tests and exhaled nitric oxide. Severe asthma was defined as poorly controlled asthma despite treatment with > or = 800 microg budesonide or equivalent; assessed by a detailed structured interview.

RESULTS

The population point prevalence at age 10 years of current severe asthma was 0.5% (three of 616) and among children with current asthma 4.5% (three of 67). The 10/154 children identified as suffering from severe asthma more often had severe bronchial hyperresponsiveness (PD(20) methacholine <1 micromol) (60%vs 22%, P = 0.015), lower median forced expiratory volume in 1 s/forced vital capacity ratio (93%vs 99%, P = 0.04) and higher body mass index (mean BMI 22.3 vs 18.3, P < 0.001) than nonsevere current asthmatics.

CONCLUSIONS

The prevalence of severe asthma was 0.5% in all 10-year olds, and 4.5% among current asthmatics. The severe asthma definition applied in this study is supported by results of clinical investigations.

Exercise-induced hypersensitivity syndromes in recreational and competitive athletes: a PRACTALL consensus report (what the general practitioner should know about sports and allergy)

Exercise-induced (EI) hypersensitivity disorders are significant problems for both recreational and competitive athletes. These include EI-asthma, EI-bronchoconstriction, EI-rhinitis, EI-anaphylaxis and EI-urticaria. A group of experts from the European Academy of Allergology and Clinical Immunology and the American Academy of Allergy Asthma and Immunology met to discuss the pathogenesis of these disorders and how to diagnose and treat them, and then to develop a consensus report. Key words (exercise with asthma, bronchoconstriction, rhinitis, urticaria or anaphylaxis) were used to search Medline, the Cochrane database and related websites through February 2008 to obtain pertinent information which, along with personal reference databases and institutional experience with these disorders, were used to develop this report. The goal is to provide physicians with guidance in the diagnosis, understanding and management of EI-hypersensitivity disorders to enable their patients to safely return to exercise-related activities.

A case-control study of the relation between plasma selenium and asthma in European populations: a GAL2EN project

BACKGROUND

There is evidence that selenium levels are relatively low in Europe and may be falling. Low levels of selenium or low activity of some of the enzymes dependent on selenium have been associated with asthma.

METHODS

The GA(2)LEN network has organized a multicentre case-control study in Europe to assess the relation of plasma selenium to asthma. The network compared 569 cases in 14 European centres with a diagnosis of asthma and reporting asthma symptoms in the last 12 months with 576 controls from the same centres with no diagnosis of asthma and no asthmatic symptoms in the last 12 months.

RESULTS

All cases and controls were selected from the same population defined by age and place of residence. Mean plasma selenium concentrations among the controls ranged from 116.3 microg/l in Palermo to 67.7 microg/l in Vienna and 56.1 microg/l among the children in Oslo. Random effects meta-analysis of the results from the centres showed no overall association between asthma and plasma selenium [odds ratio (OR)/10 microg/l increase in plasma selenium: 1.04; 95% confidence interval (CI): 0.89-1.21] though there was a significantly protective effect in Lodz (OR: 0.48; 95% CI: 0.29-0.78) and a marginally significant adverse effect in Amsterdam (OR: 1.68; 95% CI: 0.98-2.90) and Ghent (OR: 1.35; 95% CI: 1.03-1.77).

CONCLUSION

This study does not support a role for selenium in protection against asthma, but effect modification and confounding cannot be ruled out.