Allergy and respiratory health effects of dampness and dampness-related agents in schools and homes: a cross-sectional study in Danish pupils.

Little is known about the health effects of school-related indoor dampness and microbial exposures. In this study, we investigated dampness and dampness-related agents in both homes and schools and their association with allergy and respiratory health effects in 330 Danish pupils. Classroom dampness was identified based on technical inspection and bedroom dampness on parents' self-report. Classroom and bedroom dust was analyzed for seven microbial components. Skin prick testing determined atopic sensitization. Lung function was expressed as z-scores for forced expiratory volume in one-second (zFEV1 ), forced vital capacity (zFVC) and the ratio zFEV1 /zFVC using GLI-2012 prediction equations. The parents reported children's allergies, airway symptoms, and doctor-diagnosed asthma. High classroom dampness, but not bedroom dampness, was negatively associated with zFEV1 (ß-coef. -0.71; 95% CI -1.17 to -0.23) and zFVC (ß-coef. -0.52; 95% CI -0.98 to -0.06) and positively with wheezing (OR 8.09; 95% CI 1.49 to 43.97). No consistent findings were found between any individual microbial components or combination of microbial components and health outcomes. Among other indoor risk factors, environmental tobacco smoke (ETS) decreased zFEV1 (ß-coef. -0.22; 95% CI -0.42 to -0.02) and zFEV1 /zFVCratio (ß-coef. -0.26; 95% CI -0.44 to -0.07) and increased upper airway symptoms (OR 1.66; 95% CI 1.03-2.66). In conclusion, dampness in classrooms may have adverse respiratory health effects in pupils, but microbial agents responsible for this effect remain unknown.

Determinants of house dust, endotoxin, and ß-(1→3)-D-glucan in homes of Danish children.

Little is known about the geographic variation and determinants of bacterial endotoxin and ß-(1,3)-D-glucan in Danish house dust. In a population of 317 children, we: (i) described loads and concentrations of floor dust, endotoxin, and ß-(1→3)-D-glucan and (ii) their correlations and (iii) assessed their determinants; (iv) Finally, we compared our findings with previous European studies. Bedroom floor dust was analyzed for endotoxin content by the kinetic limulus amoebocyte lysate assay and for ß-(1→3)-D-glucan by the inhibition enzyme immunoassay. The parents answered questions regarding potential determinants. We found: geometric means (geometric standard deviations) 186 mg/m(2) (4.3) for dust; 5.46 × 10(3) EU/m(2) (8.0) and 31.1 × 10(3) EU/g (2.6) for endotoxin; and 142 µg/m(2) (14.3) and 0.71 × 10(3) µg/g (7.3) for ß-(1→3)-D-glucan. High correlations (r > 0.75) were found between floor dust and endotoxin and ß-(1→3)-D-glucan loads, while endotoxin and ß-(1→3)-D-glucan concentrations were moderately correlated (r = 0.36-0.41) with the dust load. Having a carpet was positively associated with dust load and with endotoxin and ß-(1→3)-D-glucan concentrations. Pet keeping, dwelling type, and dwelling location were determinants of endotoxin concentrations. No other determinants were associated with ß-(1→3)-D-glucan concentrations. Compared with other European studies, we found lower ß-(1→3)-D-glucan loads and concentrations but higher endotoxin loads and concentrations suggesting a geographically determined different composition of Danish floor dust compared with other European regions.

Primary prevention of food allergy in children and adults: systematic review.

BACKGROUND: Food allergies can have serious physical, social, and financial consequences. This systematic review examined ways to prevent the development of food allergy in children and adults. METHODS: Seven bibliographic databases were searched from their inception to September 30, 2012, for systematic reviews, randomized controlled trials, quasi-randomized controlled trials, controlled clinical trials, controlled before-and-after studies, interrupted time series studies, and prospective cohort studies. Experts were consulted for additional studies. There were no language or geographic restrictions. Two reviewers appraised the studies using appropriate tools. Data were not suitable for meta-analysis due to heterogeneity, so were narratively synthesized. RESULTS: Seventy-four studies were included, one-third of which were of high quality. There was no good evidence to recommend that pregnant or breastfeeding women should change their diet or take supplements to prevent allergies in infants at high or normal risk. There were mixed findings about the preventive benefits of breastfeeding for infants at high or normal risk, but there was evidence to recommend avoiding cow's milk and substituting with extensively or partially hydrolyzed whey or casein formulas for infants at high risk for the first 4 months. Soy milk and delaying the introduction of solid foods beyond 4 months did not have preventive benefits in those at high or normal risk. There was very little evidence about strategies for preventing food allergy in older children or adults. CONCLUSIONS: There is much to learn about preventing food allergy, and this is a priority given the high societal and healthcare costs involved.

Acute and long-term management of food allergy: systematic review.

BACKGROUND: Allergic reactions to food can have serious consequences. This systematic review summarizes evidence about the immediate management of reactions and longer-term approaches to minimize adverse impacts. METHODS: Seven bibliographic databases were searched from their inception to September 30, 2012, for systematic reviews, randomized controlled trials, quasi-randomized controlled trials, controlled clinical trials, controlled before-and-after and interrupted time series studies. Experts were consulted for additional studies. There was no language or geographic restrictions. Two reviewers critically appraised the studies using the appropriate tools. Data were not suitable for meta-analysis due to heterogeneity so were narratively synthesized. RESULTS: Eighty-four studies were included, but two-thirds were at high risk of potential bias. There was little evidence about acute management for non-life-threatening reactions. H1-antihistamines may be of benefit, but this evidence was in part derived from studies on those with cross-reactive birch pollen allergy. Regarding long-term management, avoiding the allergenic food or substituting an alternative was commonly recommended, but apart from for infants with cow's milk allergy, there was little high-quality research on this management approach. To reduce symptoms in children with cow's milk allergy, there was evidence to recommend alternatives such as extensively hydrolyzed formula. Supplements such as probiotics have not proved helpful, but allergen-specific immunotherapy may be disease modifying and therefore warrants further exploration. CONCLUSIONS: Food allergy can be debilitating and affects a significant number of people. However, the evidence base about acute and longer-term management is weak and needs to be strengthened as a matter of priority.

EAACI food allergy and anaphylaxis guidelines: diagnosis and management of food allergy.

Food allergy can result in considerable morbidity, impact negatively on quality of life, and prove costly in terms of medical care. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Guidelines for Food Allergy and Anaphylaxis Group, building on previous EAACI position papers on adverse reaction to foods and three recent systematic reviews on the epidemiology, diagnosis, and management of food allergy, and provide evidence-based recommendations for the diagnosis and management of food allergy. While the primary audience is allergists, this document is relevant for all other healthcare professionals, including primary care physicians, and pediatric and adult specialists, dieticians, pharmacists and paramedics. Our current understanding of the manifestations of food allergy, the role of diagnostic tests, and the effective management of patients of all ages with food allergy is presented. The acute management of non-life-threatening reactions is covered in these guidelines, but for guidance on the emergency management of anaphylaxis, readers are referred to the related EAACI Anaphylaxis Guidelines.

Associations between selected allergens, phthalates, nicotine, polycyclic aromatic hydrocarbons, and bedroom ventilation and clinically confirmed asthma, rhinoconjunctivitis, and atopic dermatitis in preschool children.

Previous studies, often using data from questionnaires, have reported associations between various characteristics of indoor environments and allergic disease. The aim of this study has been to investigate possible associations between objectively assessed indoor environmental factors and clinically confirmed asthma, rhinoconjunctivitis, and atopic dermatitis. The study is a cross-sectional case-control study of 500 children aged 3-5 years from Odense, Denmark. The 200 cases had at least two parentally reported allergic diseases, while the 300 controls were randomly selected from 2835 participating families. A single physician conducted clinical examinations of all 500 children. Children from the initially random control group with clinically confirmed allergic disease were subsequently excluded from the control group and admitted in the case group, leaving 242 in the healthy control group. For most children, specific IgE's against various allergens were determined. In parallel, dust samples were collected and air change rates were measured in the children's bedrooms. The dust samples were analyzed for phthalate esters, polycyclic aromatic hydrocarbons (PAH), nicotine, and various allergens. Among children diagnosed with asthma, concentrations of nicotine were higher (P < 0.05) and cat allergens were lower (P < 0.05) compared with the healthy controls; air change rates were lower for those sensitized (specific IgE+) compared with those not sensitized (specific IgE-, P < 0.05); and dust mite allergens were higher for specific IgE+ cases compared with healthy controls (P < 0.05). When disease status was based solely on questionnaire responses (as opposed to physician diagnosis), significant associations were found between di(2-ethylhexyl) phthalate (DEHP) and dog allergens in dust and current wheeze.

Study of the feasibility of outpatient sacrocolpopexy by laparoscopy.

INTRODUCTION: Laparoscopic sacrocolpopexy (LSCP) is currently the gold standard surgical technique for treating pelvic prolapse. This study aimed to evaluate the feasibility of laparoscopic sacrocolpopexy in ambulatory care. PATIENTS AND METHODS: This prospective study was conducted to evaluate the feasibility of LSCP in women who visited the outpatient department of obstetrics and gynecology at the University Hospital of Strasbourg between July 2018 and December 2021. All women with indications for laparoscopic sacrocolpopexy for prolapse treatment who were willing to be treated as outpatients were included. The main criterion of the study was to evaluate the rate of re-hospitalization between discharge from the outpatient department after LSCP and postoperative follow-up consultations. RESULTS: Among the whole population (57/200, 28.5 %) included, 4 (7 %) were hospitalized. The quality of life was not altered with a preserved EuroQol (EQ-5D) quality of life score with a mean score of 73±18.4 standard deviation (SD) 95 % confidence interval (CI) (67.9; 78.1) on postoperative day 3 (D3) and 91.2 ± 16.3 SD 95 % CI (86.2-96) on D30. On D1, D2, D3, and D7, the anxiety rate evaluated by State-Trait Anxiety Inventory score (STAI Y-A) remained low, with mean scores of 24.8 ± 9.6 SD 95 % [23.4-26.5] on D30. All patients were satisfied or very satisfied with the procedure and outpatient management, with an average score of 9.6/10 (range: 8-10). CONCLUSION: This prospective, monocentric study evaluating the feasibility of outpatient LSCP reported demonstrated low rates of complications and re-hospitalization after outpatient management. Furthermore, the patients' quality of life was not altered, and they patients were satisfied with this type of management.

Testing children for allergies: why, how, who and when: an updated statement of the European Academy of Allergy and Clinical Immunology (EAACI) Section on Pediatrics and the EAACI-Clemens von Pirquet Foundation.

Allergic diseases are common in childhood and can cause a significant morbidity and impaired quality-of-life of the children and their families. Adequate allergy testing is the prerequisite for optimal care, including allergen avoidance, pharmacotherapy and immunotherapy. Children with persisting or recurrent or severe symptoms suggestive for allergy should undergo an appropriate diagnostic work-up, irrespective of their age. Adequate allergy testing may also allow defining allergic trigger in common symptoms. We provide here evidence-based guidance on when and how to test for allergy in children based on common presenting symptoms suggestive of allergic diseases.

Children's health and its association with indoor environments in Danish homes and daycare centres - methods.

UNLABELLED: The principle objective of the Danish research program 'Indoor Environment and Children's Health' (IECH) was to explore associations between various exposures that children experience in their indoor environments (specifically their homes and daycare centers) and their well-being and health. The targeted health endpoints were allergy, asthma, and certain respiratory symptoms. The study was designed with two stages. In the first stage, a questionnaire survey was distributed to more than 17,000 families with children between the ages of 1 and 5. The questionnaire focused on the children's health and the environments within the homes they inhabited and daycare facilities they attended. More than 11,000 questionnaires were returned. In the second stage, a subsample of 500 children was selected for more detailed studies, including an extensive set of measurements in their homes and daycare centers and a clinical examination; all clinical examinations were carried out by the same physician. In this study, the methods used for data collection within the IECH research program are presented and discussed. Furthermore, initial findings are presented regarding descriptors of the study population and selected characteristics of the children's dwellings and daycare centers. PRACTICAL IMPLICATIONS: This study outlines methods that might be followed by future investigators conducting large-scale field studies of potential connections between various indoor environmental factors and selected health endpoints. Of particular note are (i) the two-stage design - a broad questionnaire-based survey followed by a more intensive set of measurements among a subset of participants who have been selected based on their responses to the questionnaire; (ii) the case-base approach utilized in the stage 2 in contrast to the more commonly used case-control approach; (iii) the inclusion of the children's daycare environment when conducting intensive sampling to more fully capture the children's total indoor exposure; and (iv) all clinical examinations conducted by the same physician. We recognize that future investigators are unlikely to fully duplicate the methods outlined in this study, but we hope that it provides a useful starting point in terms of factors that might be considered when designing such a study.

[Retrospective evaluation of relevance of care in the management of presumed benign ovarian tumors]. / Évaluation rétrospective de la pertinence des soins dans la prise en charge des tumeurs ovariennes présumées bénignes.

INTRODUCTION: The relevance of care is defined by the right act, for the right patient, at the right time. We were interested in the relevance of the management of presumed benign ovarian tumors before and after the release of the CNGOF guidelines 2013 (French guidelines). METHODS: This is a retrospective observational study conducted at the University Hospital in Strasburg France from 01/01/2013 to 31/12/2017 including all patients treated for a presumed benign ovarian cyst. We were interested in the diagnostic approach: relevance of the prescribed imaging and the use of CA 125 dosage, in the therapeutic approach: the relevance of the technique used as well as the relevance of the surgical indication. We compared our practices between 2013 and 2017 for these same items. RESULTS: We included 682 cysts for 621 patients, the imaging performed was relevant in 55% of cases, not relevant but justified in 25% and irrelevant in 20%. The CA 125 assay or its absence of assay was relevant in 84% of cases. The surgical technique was relevant in 67% of cases and not relevant but justified in 29%. With a significant improvement 7.1% in 2013 of irrelevant against 0.9% for the year 2017. The surgical indication was relevant in 72% of cases, not relevant but justified in 20% and irrelevant in 2.7%. CONCLUSIONS: The analysis of the relevance of care allows an evaluation of our practices. Professional recommendations can have an impact on the quality of care.

Food allergy and food sensitization in early childhood: results from the DARC cohort.

BACKGROUND: The prevalence of food hypersensitivity (FHS) and the relationship with atopic dermatitis (AD) is controversial. The aim of this study was to determine the development of FHS and to correlate this with AD in relation to sensitization and symptoms. METHODS: This study combines new data from birth to 18 months of age with previous published results from 3 and 6 years. The Danish Allergy Research Centre cohort, including 562 children, is a unique, population-based, prospective birth cohort, with clinical examinations at all follow-ups. All children were examined for the development of AD using Hanifin-Rajka criteria and for FHS using interviews, skin prick test (SPT), specific immunoglobulin E (IgE), and food challenge according to EAACI guidelines. RESULTS: Twenty children were confirmed with FHS to milk, egg, and peanut. FHS peaked at 18 months (3.6%) and then decreased to 1.2% at 72 months of age. No new cases were found after 3 years. Self-reporting could only be confirmed in 31% of cases. Among the 122 children with AD, 18 had FHS (14.8%). FHS was IgE-mediated in 95% of the cases but 16 of 20 children were additionally sensitized to other foods which they tolerated. Children with AD were neither more IgE-sensitized nor had higher levels of IgE when compared with healthy children but they were more persistently sensitized. CONCLUSIONS: Sensitization to foods in young children without food allergy seems to be a normal phenomenon. The discrepancy between sensitization, self-reported food-related symptoms and confirmed FHS illustrates the need to perform standardized oral challenges in order to confirm the diagnosis of FHS.

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.

[Laparoscopic treatment of cesarean scar pouch - A case series study of 9 patients]. / Prise en charge cœlioscopique des isthmocèles ­ Étude d'une série de 9 cas.

OBJECTIVES: To study the effects of laparoscopic repair of isthmoceles acquired after a cesarean section on symptoms and fertility. METHODS: This retrospective case series study included symptomatic women (abnormal uterine bleeding and/or pelvic pain and/or infertility) suffering from a large isthmocele and treated laparoscopically in our center. The surgical procedure consisted in resecting the pouch and suturing the scar in 2 layers. The patient follow-up has been realised through the postoperative control, the medical file and a survey, and concerned the evolution of the symptoms and fertility. RESULTS: Nine patients have been included, all suffering from large isthmoceles, diagnosed by transvaginal ultrasound associated with hysteroscopy, hysterosalpingography or MRI. Postoperatively, the symptoms disappeared in 78% of the patients. There have been 4 spontaneous pregnancies in 4 patients, 3 of them had been diagnosed with infertility. The median patient medical follow-up lasted 28 months. CONCLUSION: The diagnosis of a large isthmocele in patients suffering from invalidant symptoms and infertility should lead to consider a surgical treatment which is an efficient and surgically safe procedure.

Prevention.

The development of food allergy depends on several factors, including genetic factors and early exposure to allergenic proteins in the diet, food protein uptake and handling, and the development of tolerance. Many hypotheses, as regards the possible causal relationships, have been raised during the past few years, including the hygiene theory, the role of bacterial gut flora, and the potential effect of different cytokines in breast milk. Although interesting, these are mainly speculations based on non-interventional and often retrospective/cross-sectional studies including small study populations. These theories remain to be documented in proper, controlled and prospective studies. Breastfeeding and the late introduction of solid foods (>4 months) is associated with a reduced risk of food allergy, atopic dermatitis, and recurrent wheezing and asthma in early childhood. In all infants, breastfeeding should be encouraged for 4-6 months. In high-risk infants a documented extensively hydrolysed formula is recommended if exclusive breastfeeding is not possible for the first 4 months of life. There is no evidence for preventive dietary intervention neither during pregnancy nor lactation. Preventive dietary restrictions after the age of 4-6 months are not scientifically documented.

The natural history of cow's milk protein allergy/intolerance.

In prospective studies th incidence of cow's milk protein allergy and intolerance (CMPA/CMPI) in infancy in western industrialized countries has been estimated to be about 2-3% based on strict diagnostic criteria. A significant association between early neonatal exposure to cow's milk formula feeding and subsequent development of CMPA/CMPI has been documented. The small amounts of 'foreign' protein in human milk may rather induce tolerance than allergic sensitization. The findings of specific IgE to individual cow's milk proteins in cord blood of the majority of infants who later develop CMPA/CMPI suggests a prenatal sensitization may play a role in the pathogenesis of CMPA/CMPI. Perhaps a weak intrauterine education of low IgE-response may need to 'boosted' neonatally in order to cause clinical disease. The prognosis of CMPA/CMPI is good with a recovery of about 45-56% at one year, 60-77% at two years and 71-87% at three years. Associated adverse reactions to other foods, especially egg, soy, peanut and citrus develop in about 41-54%. Allergy to potential environmental inhalant allergens has been reported in up to 28% by three years and up to 80% before the age of puberty. Especially, infants with an early increased IgE response to cow's milk protein have an increased risk of persisting CMPA, development of persistent adverse reactions to other foods and development of allergy against environmental inhalant allergens. Cow's milk protein/intolerance (CMPA/CMPI), meaning reproducible adverse reactions to cow's milk protein(s) may be due to the interaction between one or more milk proteins and one or more immune mechanisms, possible any of the four basic types of hypersensitivity reactions. Immunologically mediated reactions are defined as CMPA. Mostly, CMPA is caused by IgE-mediated (type I) reactions, but evidence for type III (immune complex) reactions and type IV (cell mediated reactions) have been demonstrated as reviewed by Høst (1994) and Ortolani & Vighi (1995). Non immunologically reactions against cow's milk protein(s) are defined as CMPI. However, it should be stressed that many studies on 'cow's milk allergy' have not investigated the immunological basis of the clinical reactions. In most instances of cow's milk protein hypersensitivity only diagnostic investigations such as skin prick test and RAST indicative of IgE-mediated reactions are performed. In fact, CMPA cannot be ruled out unless extensive diagnostic tests for type II-III-IV reactions have proved negative. Thus, the classification of adverse reactions to cow's milk proteins depends on the extent and the quality of performed diagnostic tests for immune mediated reactions. At present, no single laboratory test is diagnostic of CMPA/CMPI, and differentiation between CMPA and CMPI cannot be based solely on clinical symptoms. Therefore the diagnosis has to be based on strict well-defined elimination and milk challenge procedure (Hill & Hosking, 1991), (Høst, 1994). Preferably, double-blind placebo-controlled challenges (DBPCFC) should be carried out in children older than 1-2 years of age. In infants open controlled challenges have been shown to be reliable when performed under professional observation in a hospital setting (Høst & Halken, 1990).

The effect of hypo-allergenic formulas in infants at risk of allergic disease.

Development of atopic disease seems to depend on both genetic factors and exposure to several environmental factors. At present ther is evidence that the mode of early infant feeding influences the development of food allergy, whereas daily exposure to inhalant allergens and daily exposure to tobacco smoke is found to be associated with an increased risk of recurrent wheezing/asthma and inhalant allergy. In infants with atopic predisposition (first-degree relatives), exclusively breastfeeding > or = four months is found associated with a significant reduction of the cumulative prevalence of cow's milk allergy/intolerance (CMA/CMI) during the first 1-2 years of age. When breastmilk is insufficient or lacking a substitute formula is needed. Several recent prospective studies show a preventative effect of extensively hydrolysed formula (eHF) in combination with avoidance of cow's milk proteins and solid foods during > or = 4 months in high-risk infants on the cumulative prevalence of food allergy and atopic dermatitis during the first 2-4 years of life. Partially hydrolysed formulas (pHF) may be effective in allergy prevention, but due to drawbacks of study design and lack of documentation pHF cannot be recommended at present. The results of studies comparing the preventive effect of eHF and pHF are awaited. The protective effect on the development of cow's milk allergy is a real prevention and not only a postponement of the onset of symptoms. No studies have demonstrated a preventive effect of dietary measures as regards asthma/inhalant allergy, at present until the age of four years. As no studies concerning the preventive effect of avoidance of milk and other foods after the age of 4-6 months of life have been performed, recommendation of preventive elimination diets beyond this age is empirically based. In order to reduce the costs, to minimize the risk of stigmatisation and the risk of malnutrition it is important to avoid unnecessary restrictive and prolonged diets. A diet period of 4-6 months seems sufficient in most infants. At present eHF are recommended for avoidance of cow's milk. Some high risk infants may benefit from maternal diet during lactation, but there is no documented beneficial effect of maternal diet during pregnancy.

Hypertrophic pyloric stenosis: determination of muscle dimensions by ultrasound.

To evaluate the usefulness of ultrasound in hypertrophic pyloric stenosis (HPS) and to analyse the correlation between the dimensions of the pyloric muscle and the age and the weight of the child, 34 children with suspected HPS and 34 controls were examined. An overlap between the dimensions of the pyloric muscle in the HPS group and in the controls stresses the need to assess the muscle length, the muscle diameter, and the muscle wall thickness in establishing the sonographic diagnosis of HPS. We found the following criteria useful: muscle length greater than or equal to 19 mm, muscle diameter greater than or equal to 10 mm, and muscle wall thickness greater than or equal to 4 mm. The results did not confirm previous reports of increasing dimensions of the pyloric muscle with age and weight.