Associations of wheezing phenotypes in the first 6 years of life with atopy, lung function and airway responsiveness in mid-childhood

Background:

Patterns of wheezing during early childhood may indicate differences in aetiology and prognosis of respiratory illnesses. Improved characterisation of wheezing phenotypes could lead to the identification of environmental influences on the development of asthma and airway diseases in predisposed individuals.

Methods:

Data collected on wheezing at seven time points from birth to 7 years from 6265 children in a longitudinal birth cohort (the ALSPAC study) were analysed. Latent class analysis was used to assign phenotypes based on patterns of wheezing. Measures of atopy, airway function (forced expiratory volume in 1 s (FEV₁), mid forced expiratory flow (FEF_25-75)) and bronchial responsiveness were made at 7–9 years of age.

Results:

Six phenotypes were identified. The strongest associations with atopy and airway responsiveness were found for intermediate onset (18 months) wheezing (OR for atopy 8.36, 95% CI 5.2 to 13.4; mean difference in dose response to methacholine 1.76, 95% CI 1.41 to 2.12 %FEV₁ per μmol, compared with infrequent/never wheeze phenotype). Late onset wheezing (after 42 months) was also associated with atopy (OR 6.6, 95% CI 4.7 to 9.4) and airway responsiveness (mean difference 1.61, 95% CI 1.37 to 1.85 %FEV₁ per μmol). Transient and prolonged early wheeze were not associated with atopy but were weakly associated with increased airway responsiveness and persistent wheeze had intermediate associations with these outcomes.

Conclusions:

The wheezing phenotypes most strongly associated with atopy and airway responsiveness were characterised by onset after age 18 months. This has potential implications for the timing of environmental influences on the initiation of atopic wheezing in early childhood.

Effect of environmental manipulation in pregnancy and early life on respiratory symptoms and atopy during first year of life: a randomised trial

BACKGROUND

Asthma places huge demands on health-care services, and its prevalence is increasing. Reduction of exposure to environmental allergens could offer a realistic chance for primary prevention. Our aim was to ascertain whether or not living in a low-allergen environment reduces the risk of asthma and atopic diseases in infants.

METHODS

We assigned infants to four risk groups according to parental atopic status. We enrolled 291 high-risk couples (both parents atopic, no pets) into a prospective, prenatally randomised, cohort study, and allocated them to environmental manipulation, in which measures to reduce prenatal and postnatal allergen exposure were undertaken (active HRA) (n=145) or no intervention (control HRC) (n=146). Two further prospective groups were studied: 161 high-risk infants with pets in the home (HRP group) and 168 low-risk infants, whose parents were both non-atopic (LR group). The main outcome measures were signs and symptoms of atopic disease at 1 year of age.

FINDINGS

103 families dropped out or were lost to follow up. At age 1 year we followed-up 133 HRA, 118 HRC, 140 HRP, and 126 LR infants. Children in the HRA group were less likely to have respiratory symptoms during the first year of life than those in the HRC group. The most pronounced differences were in the relative risks for severe wheeze with shortness of breath (relative risk 0.44 [95% CI 0.20-1.00]), prescribed medication for the treatment of wheezy attacks (0.58 [0.36-0.95]), and wheezing after vigorous playing, crying, or exertion (0.18 [0.04-0.79]). Probability of respiratory symptoms in HRC and HRP infants was similar, whereas it was much lower in the LR than in the HRC group. Cat ownership was significantly associated with sensitisation to cats (24.6 [3.04-199.05]; p=0.003).

INTERPRETATION

Environmental manipulation reduces some respiratory symptoms in the first year of life in high-risk infants. Further follow up is needed, however, to ascertain whether living in a low-allergen environment reduces allergy and asthma in later life.

Dynamic Consent: a potential solution to some of the challenges of modern biomedical research

Background

Innovations in technology have contributed to rapid changes in the way that modern biomedical research is carried out. Researchers are increasingly required to endorse adaptive and flexible approaches to accommodate these innovations and comply with ethical, legal and regulatory requirements. This paper explores how Dynamic Consent may provide solutions to address challenges encountered when researchers invite individuals to participate in research and follow them up over time in a continuously changing environment.

Methods

An interdisciplinary workshop jointly organised by the University of Oxford and the COST Action CHIP ME gathered clinicians, researchers, ethicists, lawyers, research participants and patient representatives to discuss experiences of using Dynamic Consent, and how such use may facilitate the conduct of specific research tasks. The data collected during the workshop were analysed using a content analysis approach.

Results

Dynamic Consent can provide practical, sustainable and future-proof solutions to challenges related to participant recruitment, the attainment of informed consent, participant retention and consent management, and may bring economic efficiencies.

Conclusions

Dynamic Consent offers opportunities for ongoing communication between researchers and research participants that can positively impact research. Dynamic Consent supports inter-sector, cross-border approaches and large scale data-sharing. Whilst it is relatively easy to set up and maintain, its implementation will require that researchers re-consider their relationship with research participants and adopt new procedures.

BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007)

This is an updated guideline for the diagnosis and management of allergic and non-allergic rhinitis, first published in 2007. It was produced by the Standards of Care Committee of the British Society of Allergy and Clinical Immunology, using accredited methods. Allergic rhinitis is common and affects 10-15% of children and 26% of adults in the UK, it affects quality of life, school and work attendance, and is a risk factor for development of asthma. Allergic rhinitis is diagnosed by history and examination, supported by specific allergy tests. Topical nasal corticosteroids are the treatment of choice for moderate to severe disease. Combination therapy with intranasal corticosteroid plus intranasal antihistamine is more effective than either alone and provides second line treatment for those with rhinitis poorly controlled on monotherapy. Immunotherapy is highly effective when the specific allergen is the responsible driver for the symptoms. Treatment of rhinitis is associated with benefits for asthma. Non-allergic rhinitis also is a risk factor for the development of asthma and may be eosinophilic and steroid-responsive or neurogenic and non- inflammatory. Non-allergic rhinitis may be a presenting complaint for systemic disorders such as granulomatous or eosinophilic polyangiitis, and sarcoidoisis. Infective rhinitis can be caused by viruses, and less commonly by bacteria, fungi and protozoa.

Genome-wide association study to identify genetic determinants of severe asthma

BACKGROUND

The genetic basis for developing asthma has been extensively studied. However, association studies to date have mostly focused on mild to moderate disease and genetic risk factors for severe asthma remain unclear.

OBJECTIVE

To identify common genetic variants affecting susceptibility to severe asthma.

METHODS

A genome-wide association study was undertaken in 933 European ancestry individuals with severe asthma based on Global Initiative for Asthma (GINA) criteria 3 or above and 3346 clean controls. After standard quality control measures, the association of 480 889 genotyped single nucleotide polymorphisms (SNPs) was tested. To improve the resolution of the association signals identified, non-genotyped SNPs were imputed in these regions using a dense reference panel of SNP genotypes from the 1000 Genomes Project. Then replication of SNPs of interest was undertaken in a further 231 cases and 1345 controls and a meta-analysis was performed to combine the results across studies.

RESULTS

An association was confirmed in subjects with severe asthma of loci previously identified for association with mild to moderate asthma. The strongest evidence was seen for the ORMDL3/GSDMB locus on chromosome 17q12-21 (rs4794820, p=1.03×10((-8)) following meta-analysis) meeting genome-wide significance. Strong evidence was also found for the IL1RL1/IL18R1 locus on 2q12 (rs9807989, p=5.59×10((-8)) following meta-analysis) just below this threshold. No novel loci for susceptibility to severe asthma met strict criteria for genome-wide significance.

CONCLUSIONS

The largest genome-wide association study of severe asthma to date was carried out and strong evidence found for the association of two previously identified asthma susceptibility loci in patients with severe disease. A number of novel regions with suggestive evidence were also identified warranting further study.

Manchester Asthma and Allergy Study: low-allergen environment can be achieved and maintained during pregnancy and in early life

BACKGROUND

Early exposure to dust mite allergens may be critical for primary sensitization. Reducing exposure may offer a realistic chance for primary prevention of sensitization and asthma, but it is essential to implement measures that can achieve and maintain the low-allergen environment.

OBJECTIVE

Our purpose was to assess the effectiveness of mite allergen avoidance measures in achieving and maintaining a low-allergen environment during pregnancy and in the first year of life.

METHODS

The Manchester Asthma and Allergy Study is a prospective, prenatally randomized study that follows the development of asthma and atopy in a cohort of infants at high risk (both parents atopic) who are randomly allocated to full mite allergen avoidance or to a normal regimen. Avoidance measures comprise (1) mite-proof covers (mattress, pillow, and quilt) for parental bed, (2) high-filtration vacuum cleaner, (3) vinyl flooring in infant's bedroom, (4) new crib and portable crib mattresses encased in mite-proof material, (5) benzyl benzoate (Acarosan) applied on carpets and soft furniture, (6) bed linens washed in hot water weekly, and (7) washable soft toys. Dust samples from the parental bed, bedroom floor, living room floor, infant's mattress, and nursery floor were collected between the 10th and 14th weeks of pregnancy, immediately after birth, and then at age 6 months and 1 year, and Der p 1 levels were determined by mAb-based ELISA.

RESULTS

Recovered Der p 1 from maternal mattress was reduced by 97. 25% (95% confidence interval [CI] 95.25%-98.41%) during the second and third trimesters of pregnancy, with the effect persisting for 6 months (98% reduction, 95% CI 97.25%-99.1%) and 12 months (97.6% reduction, 95% CI 95.7%-98.6%) after the birth (active vs control, P <.000001). Total Der p 1 from bedroom floor in the active group was reduced by 53.7% (95% CI 25.7%-71.2%) in samples collected within 4 weeks of the child's birth, with the percentage reduction being 62. 8% (95% CI 39.3%-77.2%) at 6 months and 26.5% (95% CI -24% to 57.1%) at 1 year (active compared vs control, P <.007). Der p 1 levels in crib mattress and nursery floor in the active group were extremely low (crib mattresses geometric mean [95% CI] 2.3 ng [1.6-3.4] at birth, 6.8 ng [4.5-10] at age 6 months, and 15.6 ng [9.8-24.8] at age 1 year [active vs control, P =.001]; nursery 1 ng [0.9-1.1] at birth, 1.7 ng [1.2-2.5] at age 6 months, and 2 ng [1.3-3.5] at age 1 year [active vs control, P <.00001]). The total amount of allergen recovered at age 1 year was 29-fold (95% CI 15.1- to 56.7-fold) higher in the control group than in the active group.

CONCLUSIONS

The avoidance measures used in this study achieved and maintained a low mite allergen environment during pregnancy and in the first year of life in homes of infants at risk of atopy.

Distribution, aerodynamic characteristics, and removal of the major cat allergen Fel d 1 in British homes

BACKGROUND

Sensitisation to cat allergen (Fel d 1) is an important risk factor for asthma in the UK. A study was undertaken to investigate the distribution of cat allergen in British homes, the aerodynamic characteristics and particle size distribution of airborne Fel d 1, and the method of removing it.

METHODS

Dust was collected from 50 homes with a cat and from 50 homes without a cat, and airborne levels of Fel d 1 were measured in 50 homes with a cat and 75 homes without a cat. Particle size distribution was determined using an Andersen sampler (8 hours/day) in 10 homes with cats. This was repeated on five separate days in a house with four cats, and then one, two, four, seven, and 14 days after the cats were removed from the living room area. The effect of high efficiency particulate air (HEPA) cleaner on airborne levels of Fel d 1 was investigated in seven homes with cats. Samples were collected on two separate days from two rooms of each house concurrently, one of which contained the cat, one day with the HEPA cleaner on and the other day as a control. Three one hourly samples were collected over a nine hour period (baseline, 4-5 hours, 8-9 hours) using a high volume dust sampler (air flow rate 60 l/min) and the air sample was collected onto a microglass fibre filter (pore size 0.3 micron).

RESULTS

Fel d 1 concentrations were much lower in houses without a cat than in those with a cat (260-fold difference (95% CI 167 to 590) in living room carpets: geometric mean (GM) 0.9 microgram/g (range 0.06-33.93) versus 237 micrograms/g (range 2.8-3000); 314-fold difference (95% CI 167 to 590) in upholstered furniture: 1.21 micrograms/g (range 0.06-61.9) versus 380 micrograms/g (range 7.1-6000); 228-fold difference (95% CI 109 to 478) in bedroom carpets: 0.24 microgram/g (range 0.06-2.24) versus 55 micrograms/g (range 0.06-2304); and 215-fold difference (95% CI 101 to 456) in mattresses: 0.2 microgram/g (range 0.06-2.3) versus 55 micrograms/g (range 0.06-3400). Airborne levels of Fel d 1 were detected in all houses with cats, and the levels varied greatly between the homes (range 0.7-38 ng/m3). Low concentrations of airborne Fel d 1 (range 0.24-1.78 ng/m3) were found in 22 of 75 homes without a cat. Although airborne Fel d 1 was mostly associated with large particles (> 9 microns, approximately 49% of the allergen recovered), small particles (< 4.7 microns) comprised approximately 23% of the total airborne allergen. Total airborne Fel d 1 was reduced by 61.7% two days after removal of the cat but this was due predominantly to the decrease in larger particles (> 4.8 microns) which fell to 13% of their baseline level. Fel d 1 levels associated with small particles (< 4.8 microns) remained largely unchanged on days 1, 2 and 4 and then slowly decreased to 33% of the baseline levels at day 14. With HEPA cleaner a significant reduction in airborne Fel d 1 was observed compared with the control sampling (GM 5.04-0.88 ng/m3 versus 3.79-1.56 ng/m3 at baseline and 8 hours, active versus control group; p = 0.008).

CONCLUSIONS

Airborne Fel d 1 was detectable in undisturbed conditions in all homes with cats and in almost a third of homes without cats. In houses with cats a significant proportion (23%) of airborne Fel d 1 was associated with small particles (< 4.7 microns diameter). Removal of the cat from the living room and bedroom areas of the home and the use of HEPA air cleaner reduced airborne levels of cat allergen in homes with cats, but the reduction following cat removal was not evenly spread across the particle size range.

Multiple atopy phenotypes and their associations with asthma: similar findings from two birth cohorts

BACKGROUND

Although atopic sensitization is one of the strongest risk factors for asthma, its relationship with asthma is poorly understood. We hypothesize that 'atopy' encompasses multiple sub-phenotypes that relate to asthma in different ways.

METHODS

In two population-based birth cohorts (Manchester and Isle of Wight - IoW), we used a machine learning approach to independently cluster children into different classes of atopic sensitization in an unsupervised manner, based on skin prick and sIgE tests taken throughout childhood and adolescence. We examined the qualitative cluster properties and their relationship to asthma and lung function.

RESULTS

A five-class solution best described the data in both cohorts, with striking similarity between the classes across the two populations. Compared with nonsensitized class, children in the class with sensitivity to a wide variety of allergens (~1/3 of children atopic by conventional definition) were much more likely to have asthma (aOR [95% CI0; 20.1 [10.9-40.2] in Manchester and 11.9 [7.3-19.4] in IoW). The relationship between asthma and conventional atopy was much weaker (5.5 [3.4-8.8] in Manchester and 5.8 [4.1-8.3] in IoW). In both cohorts, children in this class had significantly poorer lung function (FEV1 /FVC lower by 4.4% in Manchester and 2.6% in IoW; P < 0.001), most reactive airways, highest eNO and most hospital admissions for asthma (P < 0.001).

CONCLUSIONS

By adopting a machine learning approach to longitudinal data on allergic sensitization from two independent unselected birth cohorts, we identified latent classes with strikingly similar patterns of atopic response and association with clinical outcomes, suggesting the existence of multiple atopy phenotypes.

Decreased prevalence of sensitization to cats with high exposure to cat allergen

We investigated the relationship between current exposure to cat allergen and sensitization to cats. A questionnaire was administered and skin prick testing and home visits for collection of dust samples (Fel d 1; ELISA) were performed in 2502 adults (mean age, 31.8 years; age range, 18-58 years; 1251 women). The results for Fel d 1 in relation to sensitization to cats were analyzed for 10 deciles of cat allergen exposure (cut points [microg/g]: 0.05, 0.34, 0.48, 0.72, 1.13, 1.92, 7.2, 44, 151). The prevalence of sensitization to cat was significantly decreased in the lowest and the highest exposure groups. In the multivariate regression analysis (age, sex, socioeconomic status, and current smoking being adjusted for), the risk of sensitization to cats was significantly increased with medium exposure to Fel d 1 (3rd centile, OR 2.3, 95% CI 1.2-4.4, P =.01; 4th centile, OR 2.1, 95% CI 1.1-4.0, P =.03; 5th centile, OR 2.2, 95% CI 1.2-4.3, P =.04, 6th centile, OR 2.5, 95% CI 1.3-4.9, P =.005). These results indicate that the prevalence of sensitization to cat is decreased in the lowest and highest cat allergen exposure groups.

NAC Manchester Asthma and Allergy Study (NACMAAS): risk factors for asthma and allergic disorders in adults

Asthma and atopic disorders are the most common chronic diseases in the developed countries. Knowledge of the risk factors for these disorders may facilitate the development of preventive strategies aimed at reducing prevalence rates. To investigate the risk factors for asthma and allergic diseases in a large number of adults who are the parents of children in the National Asthma Campaign Manchester Asthma and Allergy Study. All pregnant women and their partners attending "Booking" antenatal clinics were invited to take part in the study. Questionnaire data were collected including the history of asthma and other atopic diseases, pet ownership and smoking habits, and skin prick tests were performed. The prevalence of atopy and the risk factors for asthma and allergic disorders were investigated in all subjects who completed the questionnaire and underwent skin testing. Statistical analysis was carried out using logistic regression. Initially, risk factors were assessed by univariate analysis to see how each potential explanatory variable affected the probability of having allergic disease. Variables were then tested in a forward stepwise multivariate analysis. In 5687 adult subjects there was a very high (48.2%) prevalence of atopy, and 9.7% of subjects had a diagnosis of asthma. In a multivariate regression analysis sensitization to dust mite, cat, dog and mixed grasses were all independently associated with asthma. The odds ratios for current asthma increased with the increasing number of positive skin tests (any two allergens - OR 4.3, 95% CI 3.3-5.5; any three allergens - OR 7.0 95% CI 5.3-9.3; all four allergens - OR 10.4, 95% CI 7.7-14; P < 0.00001). Dog ownership (OR 1.31, 95% CI 1.10-1.57; P = 0.003) and current smoking (OR 1.36, 95% CI 1.15-1.62; P = 0.0004) were significantly and directly associated with "asthma ever". Thirteen per cent of participants reported a history of eczema. In the multivariate analysis the strongest independent associate of eczema was sensitization to dog (OR 1.37, 95% CI 1.14-1.63, P < 0.0001). Apart from dog, the strength of the association between sensitization to common allergens and eczema appeared to be much lower than in the case of asthma. The prevalence of hay fever was high (20.6%), and in the multivariate analysis the association between sensitization to pollen and hay fever was extremely strong (OR 13.6, 95% CI 11.3-16.3; P < 0.0001). The results of the current study emphasize the importance of sensitization to indoor allergens in asthma. However, evidence of a possible direct role of allergen exposure in asthma causation remains unclear.

Collaborative care for depression in UK primary care: a randomized controlled trial

BACKGROUND

Collaborative care is an effective intervention for depression which includes both organizational and patient-level intervention components. The effect in the UK is unknown, as is whether cluster- or patient-randomization would be the most appropriate design for a Phase III clinical trial.

METHOD

We undertook a Phase II patient-level randomized controlled trial in primary care, nested within a cluster-randomized trial. Depressed participants were randomized to 'collaborative care' - case manager-coordinated medication support and brief psychological treatment, enhanced specialist and GP communication - or a usual care control. The primary outcome was symptoms of depression (PHQ-9).

RESULTS

We recruited 114 participants, 41 to the intervention group, 38 to the patient randomized control group and 35 to the cluster-randomized control group. For the intervention compared to the cluster control the PHQ-9 effect size was 0.63 (95% CI 0.18-1.07). There was evidence of substantial contamination between intervention and patient-randomized control participants with less difference between the intervention group and patient-randomized control group (-2.99, 95% CI -7.56 to 1.58, p=0.186) than between the intervention and cluster-randomized control group (-4.64, 95% CI -7.93 to -1.35, p=0.008). The intra-class correlation coefficient for our primary outcome was 0.06 (95% CI 0.00-0.32).

CONCLUSIONS

Collaborative care is a potentially powerful organizational intervention for improving depression treatment in UK primary care, the effect of which is probably partly mediated through the organizational aspects of the intervention. A large Phase III cluster-randomized trial is required to provide the most methodologically accurate test of these initial encouraging findings.

Sensitivity and exposure to indoor allergens in adults with differing asthma severity

In asthma, it is uncertain whether there is an association between degrees of exposure to domestic allergens and asthma severity. The pattern of sensitivity and exposure to common indoor allergens was examined in subjects with differing asthma severity. Sensitivity to house dust mite, dog and cat allergen and exposure to Der p 1, Can f 1 and Fel d 1 were assessed by skin prick tests and settled dust analysis in 28 subjects with severe asthma and 28 age- and sex-matched subjects with mild asthma (two declined skin prick test). All severe asthmatic subjects had at least one positive skin test and 20 of the 28 subjects were positive to all three allergens. Fourteen of the 26 subjects with mild asthma who took skin prick tests were positive to at least one, and one of these subjects was positive to the three allergens tested. Except for bedroom Fel d 1, the proportion of severe asthmatics both sensitized and exposed to each allergen at each site was significantly greater than the proportion sensitized and exposed in the mild asthma group. The geometric mean allergen concentrations, with the exception of bedroom Fel d 1, were greater in sensitized severe asthmatics than the sensitized mild asthmatics, which was significant for Der p 1 in bedroom samples and Can f 1 in bedroom and living room samples. These results support an association between the degrees of domestic allergen exposure in sensitized individuals and asthma severity.

Allergy in severe asthma

It is well recognized that atopic sensitization is an important risk factor for asthma, both in adults and in children. However, the role of allergy in severe asthma is still under debate. The term 'Severe Asthma' encompasses a highly heterogeneous group of patients who require treatment on steps 4-5 of GINA guidelines to prevent their asthma from becoming 'uncontrolled', or whose disease remains 'uncontrolled' despite this therapy. Epidemiological studies on emergency room visits and hospital admissions for asthma suggest the important role of allergy in asthma exacerbations. In addition, allergic asthma in childhood is often associated with severe asthma in adulthood. A strong association exists between asthma exacerbations and respiratory viral infections, and interaction between viruses and allergy further increases the risk of asthma exacerbations. Furthermore, fungal allergy has been shown to play an important role in severe asthma. Other contributing factors include smoking, pollution and work-related exposures. The 'Allergy and Asthma Severity' EAACI Task Force examined the current evidence and produced this position document on the role of allergy in severe asthma.

Reported versus confirmed wheeze and lung function in early life

AIMS

To investigate the relation between parentally reported wheeze (unconfirmed), physician confirmed wheeze, and subsequent lung function.

METHODS

Children at risk of allergic disease (one parent atopic) were recruited antenatally and followed prospectively from birth. During the first three years of life parents were asked to contact the study team if their child was wheezy. The presence of wheeze was confirmed or not by the primary care or study physician. Respiratory questionnaire and specific airway resistance measurement (sR(aw), body plethysmograph) were completed at age 3 years.

RESULTS

A total of 454 children were followed from birth to 3 years of age. One hundred and eighty six (40.9%) of the parents reported their child wheezing in the first three years of life, and in 130 (28.6%) the wheeze was confirmed. A total of 428 children attended the three year clinic review, of whom 274 (64%) successfully carried out lung function tests. There was no significant difference in sR(aw) (kPa.s; geometric mean, 95% CI) between children who had never wheezed (n = 152; 1.03, 1.00 to 1.06) and those with a parentally reported but unconfirmed wheeze (n = 36; 1.02, 0.96 to 1.07, p = 1.00). sR(aw) was significantly higher in children with a physician confirmed wheeze (n = 86; 1.17, 1.11 to 1.22, p < 0.001) compared to those with no history of wheeze or with unconfirmed wheeze.

CONCLUSIONS

Children with physician confirmed wheeze have significantly poorer lung function compared to those with parentally reported but unconfirmed and those who have never wheezed. A proportion of parents may have little understanding of what medical professionals mean by the term "wheeze".

Rhinoconjunctivitis in 5-year-old children: a population-based birth cohort study

BACKGROUND

There is a paucity of data on the prevalence, risk factors and natural history of rhinitis in early childhood.

OBJECTIVE

Within the context of a whole-population birth cohort we investigated the prevalence of and risk factors for current rhinoconjunctivitis (CRC) at age 5 years.

METHODS

Children were followed prospectively to age 5 years [questionnaires (n = 815), skin testing (n = 717), specific immunoglobulin E (n = 478), lung function (n = 711), dry air challenge (n = 556)]. Endotoxin and allergen exposures were measured in dust samples.

RESULTS

The prevalence of rhinitis ever, current rhinitis and rhinoconjunctivitis was 28.2%, 26.1%, and 12.1%, respectively. Asthma, wheeze and eczema coexisted with CRC (P < or = 0.01). In a multivariate model, maternal asthma (OR 2.38, 95% CI: 1.30-4.38, P = 0.005), paternal hay fever (1.96, 1.11-3.46, P = 0.02) and sensitization to grass (3.46, 1.86-6.42, P < 0.001) and cat (2.42, 1.14-5.18, P = 0.02) remained significant and independent associates of CRC. Whilst almost half of children with CRC were nonatopic, there was little difference in risk factors between atopic and nonatopic CRC. Amongst children with current wheeze, the presence of concurrent CRC had no effect on either severity or frequency of wheezy episodes. There was no difference in specific airway resistance, forced expiratory volume in 1 second (FEV(1)) or airway reactivity between children with and without CRC after adjustment for the presence of wheeze.

CONCLUSION

Family history of allergic disease and sensitization to inhalant allergens are risk factors for rhinoconjunctivitis in preschool children. In this age group, there is no association between the presence of rhinoconjunctivitis and severity of wheeze, increased airway reactivity and reduced lung function.

Relationship between mite, cat, and dog allergens in reservoir dust and ambient air

BACKGROUND

Standardized methods to measure allergen exposure are essential to assess the relationship between exposure, sensitization, and asthma. Most studies have measured allergen levels in reservoir dust, although air samples may be more representative as a measure of inhaled allergen. The aim of this study was to define the relationship between mite, cat, and dog allergen content in the reservoir dust and the levels in the ambient air.

METHODS

Dust samples from the living-room floor (LF) and sofa (S) were collected in 127 homes: 62 without and 65 with pets (31 dogs, 34 cats). Air samples were taken in the same room, with a high-volume pump for 1 h (flow 60 l/min). Der p 1, Fel d 1, and Can f 1 were determined by mAb-based ELISA.

RESULTS

Airborne Der p 1 was below the detection limit (0.8 ng/m3) in all homes, with reservoir levels (GM and range) being 1.14 microg/g (0.2-66) and 1.15 microg/g (0.2-127) in LF and S, respectively. Airborne Can f 1 was detected in 40/62 homes without pets (range 0.6-12.4 ng/m3) and in all homes with dogs (range 0.5-99 ng/m3). In the multiple linear regression analysis, Can f 1 level in the LF was an independent correlate of the airborne Can f 1 (P=0.01, homes with dogs; P=0.04, homes without dogs). Fel d 1 was detected in the air in 16/62 homes without pets (range 0.16-1.8 ng/m3) and in all homes with cats (range 0.4-22.3 ng/m3). Fel d 1 level in the LF was an independent correlate of the airborne Fel d 1 in homes without cats (P=0.008), but airborne levels in homes with cats did not correlate with reservoir levels.

CONCLUSIONS

The aerodynamics of each allergen must be taken into account when assessing exposure: while levels in reservoir dust are the best available index for mite allergens, airborne levels might be more suitable for defining exposure to pets. If air samples are difficult to obtain, levels of Can f 1 and Fel d 1 in the LF samples should be used as a surrogate measure of personal exposure.

Human argininosuccinate lyase: a structural basis for intragenic complementation

Intragenic complementation has been observed at the argininosuccinate lyase (ASL) locus. Intragenic complementation is a phenomenon that occurs when a multimeric protein is formed from subunits produced by different mutant alleles of a gene. The resulting hybrid protein exhibits enzymatic activity that is greater than that found in the oligomeric proteins produced by each mutant allele alone. The mutations involved in the most successful complementation event observed in ASL deficiency were found to be an aspartate to glycine mutation at codon 87 of one allele (D87G) coupled with a glutamine to arginine mutation at codon 286 of the other (Q286R). To understand the structural basis of the Q286R:D87G intragenic complementation event at the ASL locus, we have determined the x-ray crystal structure of recombinant human ASL at 4. 0 A resolution. The structure has been refined to an R factor of 18. 8%. Two monomers related by a noncrystallographic 2-fold axis comprise the asymmetric unit, and a crystallographic 2-fold axis of space group P3121 completes the tetramer. Each of the four active sites is composed of residues from three monomers. Structural mapping of the Q286R and D87G mutations indicate that both are near the active site and each is contributed by a different monomer. Thus when mutant monomers combine randomly such that one active site contains both mutations, it is required by molecular symmetry that another active site exists with no mutations. These "native" active sites give rise to the observed partial recovery of enzymatic activity.

Transverse Modes and Frequencies of Beams Translating between Fixed end Supports

The effects of longitudinal steady translational motion on the vibration frequencies and modes of simple Euler beams are outlined. An example shows that the natural frequencies decrease monotonically with increasing translation velocity, while the mode shapes are complex, indicating significant phase disparities from point to point across the span. Divergence is shown to occur when the translation velocity is greater than the fundamental flexural wave propagation velocity.

More general equations of motion, governing the translating Timoshenko beam under axial loading, are derived in Appendix 1.

Exhaled nitric oxide, sensitization, and exposure to allergens in patients with asthma who are not taking inhaled steroids

The level of exhaled nitric oxide (eNO) is elevated in patients with asthma and eNO may be involved in airway inflammation. Exposure to allergen in sensitized individuals may contribute to airway inflammation. Our aim was to investigate the relationship between eNO, sensitization, and exposure to indoor allergen in nonsmoking adults with asthma who are not taking inhaled steroids. In subjects with a positive methacholine challenge (PD20 < 4 mg) we measured eNO (LR 2000 chemiluminesence analyzer); serum total and specific IgE; skin test to mite, cat, and dog; and allergen levels in domestic dust (Der p 1, Fel d 1, and Can f 1). Subjects were classified as exposed or not exposed to allergen according to previously proposed significant levels (> 2 micrograms/g Der p 1, > 8 micrograms/g Fel d 1, and > 10 micrograms/g Can f 1). Of the 43 subjects (> 95% atopic) complete data were available for 38, of whom 26 were both sensitized and exposed to one or more allergen and 12 were sensitized but not exposed to any allergens. eNO was significantly higher in those subjects who were both sensitized and exposed to indoor allergen than in those who were sensitized but not exposed (GM and 95% CI: 17. 69 [14.1- 22.15] versus 9.09 [6.5-12.7], p = 0.001). Levels of eNO are significantly higher in patients with asthma who are both sensitized and exposed to relevant allergen than in those who were sensitized but not exposed. eNO may be a marker of the airway inflammation induced by domestic exposure to allergen in sensitized patients with asthma.

Neural mechanisms of reflex facilitation and inhibition of gastric motility to stimulation of various skin areas in rats

1. Experiments were performed on chloralose-urethane anaesthetized rats to determine the involvement of extrinsic gastric autonomic nerves in reflex facilitation and inhibition of gastric motility when mechanical nociceptive stimulation was delivered to either hind paw or abdominal skin, respectively. 2. After bilaterally sectioning the splanchnic nerves in vagal intact animals, the reflex facilitation of gastric motility produced by hind paw stimulation persisted, but the reflex inhibition previously produced by abdominal skin stimulation disappeared. 3. Hind paw stimulation increased efferent activity of the gastric branch of the vagus nerve, but stimulation of abdominal skin had little influence. 4. Bilateral vagotomy in splanchnic nerve intact animals did not influence the gastric reflex inhibition by abdominal skin stimulation, but either abolished gastric reflex facilitation produced by hind paw stimulation or reversed the reflex facilitation response to slight reflex inhibition. 5. Efferent activity of the gastric sympathetic nerve was greatly increased by abdominal skin stimulation, and was either slightly increased or not influenced by hind paw stimulation. 6. It was concluded that reflex increase of efferent activity of the gastric vagi was responsible for the gastric motility facilitation produced by hind paw stimulation, and also that reflexly increased efferent activity of the gastric sympathetic nerves resulted in gastric motility inhibition produced by abdominal skin stimulation. It is suggested efferents are inhibitory. 7. After spinal transection at the cervical level, the reflex facilitation of gastric motility previously produced by stimulation of a hind paw was completely abolished, or reversed to slight reflex inhibition, while reflex inhibition of gastric motility produced by stimulation of abdominal skin remained. It was concluded that the gastric reflex inhibition was a spinal reflex. 8. Interaction between reflex facilitation and inhibition of gastric motility during simultaneous stimulation of both hind paws and abdominal skin was observed as partial cancellation of each effect by the other. However, sympathetic reflex inhibition of gastric motility seemed to be much stronger than the vagal reflex facilitatory effect.

Screening for anxiety and depression in people with psoriasis: a cross-sectional study in a tertiary referral setting

BACKGROUND

National Institute for Health and Care Excellence guidance recommends assessment of psychological and social well-being in people with psoriasis.

OBJECTIVES

To screen systematically for depression and anxiety in patients with psoriasis in routine clinical practice and to identify at-risk groups for psychiatric morbidity.

METHODS

Consecutive patients attending a single, tertiary centre over a 10-month period were invited to complete the Patient Health Questionnaire Depression Scale (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7) and Dermatology Life Quality Index (DLQI) as part of IMPARTS: Integrating Mental and Physical Healthcare: Research, Training and Services. Information on demographics, treatment and clinical disease severity was collated from electronic patient records. Regression models were used to identify at-risk groups for psychiatric morbidity.

RESULTS

Of 607 patients included (56·2% on biologics), 9·9% (95% confidence interval 7·5-12·3%) screened positive for major depressive disorder (MDD) and 13·1% (79/604) (95% confidence interval 10·4-15·8%) for generalized anxiety disorder (GAD; GAD-7 score > 9). Suicidal ideation was reported in 35% of those with MDD; DLQI was < 10 in 38·3% and 45·6% cases of MDD and GAD, respectively. After adjusting for covariates, the risk of MDD or GAD was significantly higher in women and those with severe clinical disease, psoriatic arthritis and previous depression/anxiety. The risk of GAD was significantly increased with Asian ethnicity and use of topical treatments only.

CONCLUSIONS

Systematic screening for anxiety and depression identifies clinically important levels of depression and anxiety that may be missed using DLQI data alone. Women and those with severe disease, psoriatic arthritis and/or a prior history of psychiatric morbidity may be at particular risk.

The role of lipopolysaccharide in the development of atopy in humans

Atopy is a highly prevalent condition and remains the single biggest risk factor for asthma. Although atopy has a heritable component, the time frame of the increase in the prevalence indicates that it is not due to genetic factors alone. The relationship between allergen exposure and sensitization is complex. Lipopolysaccharide (LPS) and its bioactive moiety endotoxin are common to all gram-negative bacteria, and have been used as a surrogate of microbial load. Endotoxin can be readily measured in dust collected from homes. Some studies have demonstrated a clear inverse dose-response relationship between exposure to endotoxin and the risk of atopy but this finding has not been reproduced in all studies. Our innate immune system recognizes LPS readily via the LPS signal transduction pathway, which has the trimolecular complex of CD14/TLR4/MD2 at the core. A common single-nucleotide polymorphism in the promoter region of CD14 rs2569190 C to T (CD14/-260 or CD14/-159) has been associated with elevated sCD14. Although early studies suggested that this variant was associated with more severe atopy, this finding was not uniformly replicated. It has now been demonstrated in four independent populations that high exposure to endotoxin in the domestic environment is protective against the development of atopy, but only among carriers of the C allele, that is, the environmental exposure is only relevant when taken in the context of the genotype. Furthermore, this interaction is biologically plausible. We propose that neither the environmental exposure nor the genotype in isolation is sufficient to cause complex diseases like asthma and atopy, but disease results from the one acting in the context of the other, of which CD14 and endotoxin is one example contributing to the risk for atopy.