Current allergy educational needs in primary care. Results of the EAACI working group on primary care survey exploring the confidence to manage and the opportunity to refer patients with allergy.

The aim of this survey was to explore the specific educational needs of a cohort of European GPs with regards to allergy training so that future educational initiatives may better support the delivery of allergy services in primary care. METHOD: This study took the form of a cross-sectional observational study in which a structured electronic questionnaire was distributed to primary care providers, in eight languages, across 8 European countries between September 2019 and November 2019. Data associated with demographic parameters, professional qualifications, type of employment, level of confidence regarding competencies for diagnosis and treatment of allergic diseases, referral of patients to allergist and preferred method of learning and assessment were collected. A 5-point Likert scale was used to assess level of confidence. Exploratory analysis was carried out. RESULTS: A total of 687 responses were available for analysis, with 99.3% of responders working within Europe. 70.1% of participants were female; and 48.0% and 48.0% of participants respectively had received some undergraduate and/or postgraduate allergy education. Confidence in dealing with different aspect of allergy management differed between countries. The main reason for specialist referral was a perceived need for tertiary assessment (54.3%), and the main barrier for referral was the consideration that the patient's condition could be appropriately diagnosed and treated in a primary care facility. Up to 44.7% and 55.3% of participants reported that they preferred e-Learning over traditional learning. CONCLUSIONS: This study identified the specific areas of skills training and educational needs of GPs in managing allergic conditions in primary care, and provided insights into possible strategies for more feasible and cost-effective approaches.

Allergic and hypersensitivity conditions in non-specialist care: Flow diagrams to support clinical practice.

Most patients presenting with allergies are first seen by primary care health professionals. The perceived knowledge gaps and educational needs were recently assessed in response to which the LOGOGRAM Task Force was established with the remit of constructing pragmatic flow diagrams for common allergic conditions in line with an earlier EAACI proposal to develop simplified pathways for the diagnosis and management of allergic diseases in primary care. To address the lack of accessible and pragmatic guidance, we designed flow diagrams for five major clinical allergy conditions: asthma, anaphylaxis, food allergy, drug allergy, and urticaria. Existing established allergy guidelines were collected and iteratively distilled to produce five pragmatic and accessible tools to aid diagnosis and management of these common allergic problems. Ultimately, they should now be validated prospectively in primary care settings.

Development and construct validation of a parent-proxy quality of life instrument in children with bronchopulmonary dysplasia aged 4-8 years old.

PURPOSE: Children with bronchopulmonary dysplasia often develop complications that affect them well into adult life. Very little is known about how this affects their quality of life, since no sensitive instrument is available to measure health-related quality of life in this population. In this study, a Dutch parent-proxy instrument was developed for this purpose. METHODS: A list of items was generated after literature search and interviews with both parents of patients and clinical experts. Clinically relevant items were selected with the clinical impact method and item analysis. Results of clinical tests to measure complications in children with bronchopulmonary dysplasia were correlated with these items to select the items that show construct validity. Cronbach's alpha was calculated to estimate internal consistency of the items in the final questionnaire. RESULTS: In total, 92 children and their parents and 7 clinicians participated. Of 130 identified items, 47 showed clinical relevance. Spirometry, the Child Behavior Checklist, mean arterial pressure, and body mass index were used to determine construct validity of 33 items. These items were structured within five domains: pulmonary complaints, school functioning, growth and nutrition, exercise and locomotion, emotional functioning and health care concerns. The questionnaire showed excellent internal consistency with Cronbach's alpha of 0.919. CONCLUSION: This study developed a disease-specific parent-proxy instrument to measure health-related quality of life in children with bronchopulmonary dysplasia aged 4-8 years old, the BPD-QoL. All included items show construct validity and internal consistency reliability. Future research should focus on further validation and analysis of responsiveness and reliability.

The impact of oral food challenges for food allergy on quality of life: A systematic review.

BACKGROUND: Food allergy significantly impairs health-related quality of life (HRQL). Currently, it is still unknown whether diagnostic interventions for food allergy improve HRQL. We aim to assess the impact of diagnostic interventions for food allergy on HRQL. METHODS: A systematic search was performed in MEDLINE, Embase, Cochrane Library, and CINAHL focused on patients with a (suspected) food allergy who underwent diagnostic interventions (ie, skin prick test, specific IgE, or oral food challenges [OFC]) and in whom HRQL was assessed. The mean difference between HRQL before and after the diagnostic intervention was calculated. A minimal clinically important difference of 0.5 was considered clinically relevant for the food allergy quality of life questionnaire. RESULTS: Seven of 1465 original identified publications were included in which the impact of an OFC on HRQL was investigated (total patients n = 1370). No other diagnostic interventions were investigated. Food allergy-specific parent-reported HRQL improved significantly after an OFC irrespective of the outcome in children with a suspected food allergy in two publications. The change was considered clinically relevant in one of two publications. In addition, parent-reported HRQL improved after an OFC to assess the eliciting dose in children with a confirmed food allergy. The parental burden was significantly reduced after an OFC to assess resolution of food allergy. A meta-analysis could not be performed due to the limited numbers of, and considerable heterogeneity between, eligible publications. CONCLUSION: An OFC is associated with an improved food allergy-specific HRQL and a reduced parental burden of food allergy.

Association of food allergy and atopic dermatitis exacerbations.

BACKGROUND: Atopic dermatitis (AD) and food allergy frequently coexist in children. OBJECTIVE: To examine the association between food allergy and AD. METHODS: Between 2001 and 2011, children referred to our tertiary care center underwent double-blind, placebo-controlled food challenges (DBPCFCs) for one or more suspected food allergies as part of regular care. Immediate reactions were observed and recorded by allergy nursing staff, whereas late reactions were ascertained by semistructured telephone interview 48 hours after challenge. To test to which degree specific IgE results were predictive in the outcome of DBPCFCs in children with and without (previous and current) AD, logistic regression analysis was performed. RESULTS: A total of 1186 DBPCFCs were studied. Sensitization to foods occurred significantly more often in children with previous AD. The association between specific IgE results and the outcome of DBPCFCs was significant for children with and without (previous and current) AD but stronger for children without current AD. The positivity rate of DBPCFCs in children with mild, moderate, and severe AD was 53.3%, 51.7%, and 100%, respectively. Children with AD and a history of worsening AD as their only symptom reacted as often to placebo as to challenge food. CONCLUSION: Children with current AD are more frequently asymptomatically sensitized to the foods in question than those without AD. In addition, children suspected of food allergy should be considered for testing, regardless of the severity of their AD. Our results suggest that children with exacerbation of AD in the absence of other allergic symptoms are unlikely to be food allergic.

Health-related quality of life in food-allergic adults from eight European countries.

BACKGROUND: Food allergy can impair health-related quality of life (HRQL). Food Allergy Quality of Life Questionnaires (FAQLQs) have been developed and validated, including an adult form (FAQLQ-AF). HRQL has not, to date, been measured across different European countries using a uniform methodology. OBJECTIVE: To translate and validate the FAQLQ-AF for use in 8 European countries (Iceland, The Netherlands, Poland, France, Spain, Italy, Greece, and Sweden). METHODS: The English FAQLQ-AF was translated, back-translated, and compared for use in the 8 relevant European languages. Adults with a perceived food allergy were recruited from outpatient departments and through a community survey. Participants completed the FAQLQ-AF, the Food Allergy Independent Measure, and questions concerning participants' characteristics. Validity of the FAQLQ-AF was analyzed for use in the 8 countries. RESULTS: The FAQLQ-AF had strong construct validity (r > 0.59) and an excellent internal consistency (Cronbach α > 0.95) in all countries. Total FAQLQ-AF scores (range 3.2-5.0) were significantly different across participating countries. CONCLUSION: The FAQLQ-AF is a suitable and valid instrument for measuring HRQL in food-allergic adults in Iceland, The Netherlands, Poland, France, Spain, Italy, Greece, and Sweden. The impact of food allergy on HRQL seems to differ among adults from the 8 participating European countries.

Quality of life is more impaired in patients seeking medical care for food allergy.

BACKGROUND: Food allergy (FA) affects 2-4% of adults, but only a small percentage visit an outpatient clinic for a thorough evaluation. METHODS: A matched case-control study was used to compare health-related quality of life (HRQL) of the Dutch general population that did not seek medical care for their FA with outpatients who did seek medical care. All participants were diagnosed as food allergic (i.e. with a suggestive history and corresponding positive IgE). HRQL was measured using the Food Allergy Quality of Life Questionnaire--Adult Form (FAQLQ-AF). A food allergy independent measure (FAIM) was used to evaluate the adult's perception of the severity of his/her disease. RESULTS: Total FAQLQ-AF score in individuals who never visited a doctor for their FA was significantly lower than that of patients who sought medical care (2.4 vs. 3.9, p = 0.03), indicating that the former had a better quality of life than patients who did seek medical care. Regarding the different domains of FAQLQ, the score for allergen avoidance and dietary restrictions and the score for emotional impact (EI) was significantly higher in the group that sought medical care (p = 0.02 and 0.03, respectively), indicating the importance of these domains. The FAIM score was significantly higher in the group that sought medical care, indicating that they perceived their FA as more severe. CONCLUSION AND CLINICAL RELEVANCE: Patients who seek medical care for their FA have a more impaired HRQL and perceive their FA as more severe. Food avoidance and issues related to the EI of FA are key areas of intervention aimed at improving HRQL in patients with FA.

Food allergy knowledge of parents - is ignorance bliss?

BACKGROUND: Food allergic children are at least partially dependent on their parents to care for their food allergy. In addition, parents are often responsible for the education of others regarding food allergy, including the family, school, neighbors, and friends. The aim of this study was to investigate food allergy knowledge, attitudes, and beliefs of parents with food allergic children in the Netherlands. In addition, a cross-cultural comparison was made between parents from the USA and parents from the Netherlands. METHODS: The original Chicago Food Allergy Research Survey for Parents of Children with Food Allergy (CFARS-PRNT) was translated into Dutch. Parents of children with at least one doctor-diagnosed food allergy were included. Knowledge scores and attitude/beliefs scores were determined and compared with the data from 2945 parents from the USA. Predictors of overall knowledge scores were investigated. RESULTS: Dutch parents of children completed the translated CFARS-PRNT (n = 299). The mean overall knowledge score in the Netherlands was 9.9 after adjusting for guessing, compared with 12.7 in the USA (p < 0.001). Attitudes and beliefs regarding food allergy among parents from the Netherlands were generally more optimistic. The overall knowledge scores could be predicted by country of origin, educational degree, being member of a patient organization, visiting an allergist, and a history of anaphylaxis. CONCLUSIONS: Food allergy knowledge among parents of food allergic children from the Netherlands is suboptimal when compared with their counterparts from the USA, although these parents tend to be more optimistic toward food allergy than parents from the USA.

Food allergy and quality of life: what have we learned?

Health-related quality of life (HRQL) has become an emerging focus of interest in food allergy. Food allergy is a disease characterized by low mortality and symptoms which only occur during an allergic reaction. However, food-allergic patients continuously need to be alert when eating in order to prevent potentially severe allergic reactions, which may be fatal. Fear of such reactions and the need to be continuously vigilant may seriously compromise their HRQL. During the last decade, numerous studies have been published on food allergy and HRQL. The development of reliable, valid and responsive instruments for measuring HRQL in food allergic patients has facilitated this research even further. Such instruments have given insight into the specific problems a patient may face and the impact of food allergy-related interventions from the patient's perspective. This paper focuses on the most significant findings regarding this topic since its first appearance in the literature in 2000.

Food allergy-related quality of life after double-blind, placebo-controlled food challenges in adults, adolescents, and children.

BACKGROUND: Currently, the longitudinal validity (validity over time) and responsiveness (ability to measure change over time) of the Food Allergy Quality of Life Questionnaire-Adult Form (FAQLQ-AF), the Food Allergy Quality of Life Questionnaire-Teenager Form (FAQLQ-TF), and the Food Allergy Quality of Life Questionnaire-Child Form (FAQLQ-CF) are unknown. Additionally, the self-reported impact of a double-blind, placebo-controlled food challenge (DBPCFC) on health-related quality of life (HRQL) in adults (≥18 years of age), adolescents (13-17 years of age), and children (8-12 years of age) is unknown. OBJECTIVE: The aims of this study were to assess the longitudinal validity and responsiveness of the FAQLQ-AF, FAQLQ-TF, and FAQLQ-CF and to assess the impact of a DBPCFC on HRQL. METHODS: Two hundred twenty-one participants suspected of food allergy were included from Dutch allergy centers. Participants undergoing a DBPCFC (experimental group) completed the FAQLQ and Food Allergy Independent Measure (FAIM) 1 month before (baseline) and 6 months after (follow-up) a DBPCFC. Participants not undergoing a DBPCFC (control group) completed the questionnaire package twice with a 7-month interval. RESULTS: HRQL scores improved after a DBPCFC, with greater improvements in HRQL scores after a negative outcome (food allergy ruled out) than a positive outcome (food allergy confirmed), demonstrating responsiveness of the FAQLQs. Significant correlations were shown between the change (follow-up minus baseline) in FAQLQ and FAIM scores supporting longitudinal validity of these questionnaires: FAQLQ-AF (Pearson correlation coefficient = 0.71, P < .001), FAQLQ-TF (Pearson correlation coefficient = 0.35, P = .018), and FAQLQ-CF (Pearson correlation coefficient = 0.51, P < .001). CONCLUSIONS: Our findings demonstrate the longitudinal validity and responsiveness of the FAQLQs. Greater improvements in HRQL scores were shown after a negative outcome than after a positive outcome.

Anticipated barriers and facilitators for implementing smart inhalers in asthma medication adherence management.

Smart inhalers are electronic monitoring devices which are promising in increasing medication adherence and maintaining asthma control. A multi-stakeholder capacity and needs assessment is recommended prior to implementation in healthcare systems. This study aimed to explore perceptions of stakeholders and to identify anticipated facilitators and barriers associated with the implementation of smart digital inhalers in the Dutch healthcare system. Data were collected through focus group discussions with female patients with asthma (n = 9) and healthcare professionals (n = 7) and through individual semi-structured interviews with policy makers (n = 4) and smart inhaler developers (n = 4). Data were analysed using the Framework method. Five themes were identified: (i) perceived benefits, (ii) usability, (iii) feasibility, (iv) payment and reimbursement, and (v) data safety and ownership. In total, 14 barriers and 32 facilitators were found among all stakeholders. The results of this study could contribute to the design of a tailored implementation strategy for smart inhalers in daily practice.

Parental eczema increases the risk of double-blind, placebo-controlled reactions to milk but not to egg, peanut or hazelnut.

BACKGROUND: While genetic factors are known to be important in the development of sensitization to foods, it is not known whether they also play a role in clinical allergic reactivity to foods. OBJECTIVE: We aimed to determine whether parental atopic diseases are associated with a higher risk of a reaction to common allergenic foods when tested in a double-blind, placebo-controlled food challenge (DBPCFC). METHODS: Parents of children suspected of being food allergic were interviewed about their own and their child's atopic history. Specific IgE and skin prick tests to food allergens and the outcome of food challenges in the child were recorded. RESULTS: Data from 553 double-blind food challenges performed in 396 children were analyzed. The foods tested were milk (n = 185), egg (n = 110), peanut (n = 198) and hazelnut (n = 60). Only parental eczema was significantly associated with positive outcomes for food challenges with milk after correction for age, sex, atopic comorbidity in the child and milk-specific IgE test results (odds ratio 3.1, 95% confidence interval 1.5-6.3). CONCLUSIONS: Children with a positive DBPCFC to milk more frequently have parents with eczema than children with a negative test. This effect of parental eczema was not seen in children challenged with egg, peanut or hazelnut. Clinical reactivity to milk may be caused by genetic factors which are shared with parental eczema to a greater extent than clinical reactivity to other foods.

Parent perceived quality of life is age-dependent in children with food allergy.

BACKGROUND: Food allergy in children significantly affects their quality of life. Its impact can be analyzed by quality of life questionnaires. OBJECTIVES: The aim of our study was to validate the French version of disease-specific questionnaires and to evaluate the quality of life in children with IgE-mediated food allergy. METHODS: Two validated food allergy-specific questionnaires for quality of life, the parent's and children's forms (FAQLQ-PF and FAQLQ-CF), were translated from English to French and submitted to children with food allergy and their parents. Questionnaires were analyzed in terms of emotional impact, food anxiety, and social and food limitations. NCT 01480427. RESULTS: Sixty-two parents of children aged 0-12 yrs answered the FAQLQ-PF, and 32 children aged 8-12 yrs the FAQLQ-CF. Construct validity of both questionnaires was assessed by correlation between the FAQLQs and FAIM (r = 0.85 and 0.84, respectively). Both FAQLQs had good internal consistency (Cronbach's α = 0.748 and 0.67, respectively). Young children (0-3 yrs old) showed better quality of life scores than older children (FAQLQ-PF global score: p = 0.02). Worse scores were also shown among children with previous severe systemic reactions (FAQLQ-PF global score: p = 0.039), the ones with an allergic mother (FAQLQ-PF global score: p = 0.002), or allergic siblings (FAQLQ-PF emotional impact score: p = 0.034), the ones with multiple food allergy (more than 1 food) (FAQLQ-PF anxiety score: p = 0.04) and among the girls (FAQLQ-CF global score: p = 0.031). CONCLUSION: Older children, the ones with severe systemic reactions, or with mothers or siblings also affected by allergies, as well as girls, and children with multiple food allergies show worse quality of life scores.

Effectiveness, usability and acceptability of a smart inhaler programme in patients with asthma: protocol of the multicentre, pragmatic, open-label, cluster randomised controlled ACCEPTANCE trial.

INTRODUCTION: Suboptimal asthma control is associated with incorrect inhaler use and poor medication adherence, which could lead to unfavourable clinical and economic outcomes. Smart inhaler programmes using electronic monitoring devices (EMDs) could support self-management and increase medication adherence and asthma control. However, evidence on long-term benefits and acceptability is scarce. This study aims to investigate the effectiveness of a smart inhaler asthma self-management programme on medication adherence and clinical outcomes in adults with uncontrolled asthma, to evaluate its acceptability and to identify subgroups who would benefit most based on patient characteristics. METHODS AND ANALYSIS: This open-label cluster randomised controlled trial of 12 months will be conducted in primary care in the Netherlands. General practices will be randomly assigned to either intervention or control group. We aim to include 242 patients. The intervention consists of (1) an EMD attached to the patient's inhaler that measures medication use; (2) a smartphone application to set medication reminders, receive motivational messages and track asthma symptoms; and (3) a portal for healthcare professionals to view data on medication use. The control group is passively monitored by the EMD but cannot view their inhaler data or receive feedback. Eligible patients are adults with suboptimal controlled asthma (Asthma Control Questionnaire score ≥0.75) with evidence of non-adherence established by the EMD during a 6-week run-in period. Primary outcome is the difference in mean medication adherence between intervention and control group. Secondary outcomes include asthma control, asthma-related quality of life, exacerbations, acceptance, cost-effectiveness and whether the effect of the intervention on medication adherence and asthma control is modified by patient characteristics (eg, self-efficacy, medication beliefs and eHealth literacy).Trial registration numberNL7854.

Extremely low prevalence of epinephrine autoinjectors in high-risk food-allergic adolescents in Dutch high schools.

The aim of the study was to estimate the prevalence of probable food allergy in adolescents aged 11-20 and to examine the frequency of epinephrine autoinjector (EAI) ownership among high-risk individuals. Adolescents were screened followed by a more detailed telephone questionnaire inquiring about suspected food(s), symptoms, diagnosis, and use of an EAI. The participating adolescents were classified as probably or unlikely to be food-allergic. The need for an EAI was assessed. In total, 2284 adolescents completed the screening questionnaire, of which 396 indicated food to be a problem and 168 agreed to be interviewed. Forty-eight adolescents were classified as probably food-allergic, of which eight were not aware of their food allergy. Twenty-three adolescents were considered candidates for an EAI, whereas only two of them had been prescribed this medication. The calculated questionnaire-based prevalence of EAI need was 3.0% (minimal prevalence at least 1.0%), whereas the EAI ownership was 0.09%. In conclusion, we found an alarming under prescription of EAIs in school-going adolescents.