Atopy in people aged 40 years and over: Relation to airflow limitation.

BACKGROUND: Previous studies have reached conflicting conclusions about the role of atopy as a risk factor for COPD. In part, this is attributable to variation in the definitions of airflow limitation and the treatment of people with asthma. OBJECTIVE: To establish whether there is any independent association between atopy and post-bronchodilator airflow limitation in the general population aged 40 years and over. METHODS: A cross-sectional survey was conducted in a general population sample of 2415 people aged 40 years and over in Australia. A history of ever being diagnosed with asthma was elicited by questionnaire. Atopy was defined as any skin prick test weal to common aeroallergens ≥4 mm. Airflow limitation was defined as post-bronchodilator spirometric (FEV1 /FVC) ratio

Geographical variation in the prevalence of sensitization to common aeroallergens in adults: the GA(2) LEN survey.

BACKGROUND: Geographical variation in the prevalence of sensitization to aeroallergens may reflect differences in exposure to risk factors such as having older siblings, being raised on a farm or other unidentified exposures. OBJECTIVE: We wanted to measure geographical variation in skin prick test positivity and assess whether it was explained by differences in family size and/or farm exposure. We also compared prevalence in younger and older subjects. METHODS: Within the Global Allergy and Asthma European Network (GA(2) LEN) survey, we measured the prevalence of skin prick positivity to a panel of allergens, and geometric mean serum total immunoglobulin E (IgE), in 3451 participants aged 18-75 years in 13 areas of Europe. Estimated prevalence was standardized to account for study design. We compared prevalence estimates in younger and older subjects and further adjusted for age, gender, smoking history, farm exposure, number of older siblings and body mass index (BMI). RESULTS: Skin prick test positivity to any one of the measured allergens varied within Europe from 31.4% to 52.9%. Prevalence of sensitization to single allergens also varied. Variation in serum total IgE was less marked. Younger participants had higher skin prick sensitivity prevalence, but not total IgE, than older participants. Geographical variation remained even after adjustment for confounders. CONCLUSION: Geographical variation in the prevalence of skin prick test positivity in Europe is unlikely to be explained by geographical variation in gender, age, smoking history, farm exposure, family size and BMI. Higher prevalence in younger, compared to older, adults may reflect cohort-associated increases in sensitization or the influence of ageing on immune or tissue responses.

The prevalence and distribution of food sensitization in European adults.

BACKGROUND: Complaints of 'food allergy' are increasing. Standardized surveys of IgE sensitization to foods are still uncommon and multicountry surveys are rare. We have assessed IgE sensitization to food-associated allergens in different regions of Europe using a common protocol. METHODS: Participants from general populations aged 20-54 years in eight European centres (Zurich, Madrid, Utrecht, Lodz, Sophia, Athens, Reykjavik and Vilnius) were asked whether they had allergic symptoms associated with specific foods. Weighted samples of those with and without allergic symptoms then completed a longer questionnaire and donated serum for IgE analysis by ImmunoCAP for 24 foods, 6 aeroallergens and, by allergen microarray, for 48 individual food proteins. RESULTS: The prevalence of IgE sensitization to foods ranged from 23.6% to 6.6%. The least common IgE sensitizations were to fish (0.2%), milk (0.8%) and egg (0.9%), and the most common were to hazelnut (9.3%), peach (7.9%) and apple (6.5%). The order of prevalence of IgE sensitization against different foods was similar in each centre and correlated with the prevalence of the pollen-associated allergens Bet v 1 and Bet v 2 (r = 0.86). IgE sensitization to plant allergen components unrelated to pollen allergens was more evenly distributed and independent of pollen IgE sensitization (r = -0.10). The most common foods containing allergens not cross-reacting with pollens were sesame, shrimp and hazelnut. DISCUSSION: IgE sensitization to foods is common, but varies widely and is predominantly related to IgE sensitization to pollen allergens. IgE sensitization to food allergens not cross-reacting with pollens is rare and more evenly distributed.

Prevalence and determinants of chronic respiratory diseases in adults in Sudan.

BACKGROUND: Chronic respiratory diseases (CRDs) are considered a significant cause of morbidity and mortality worldwide, although data from Africa are limited. This study aimed to determine the prevalence and determinants of CRDs in Khartoum, Sudan.METHODS: Data were collected from 516 participants aged ≥40 years, who had completed a questionnaire and undertook pre- and post-bronchodilator spirometry testing. Trained field workers administered the questionnaires and conducted spirometry. Survey-weighted prevalence of respiratory symptoms and spirometric abnormalities were estimated. Regression analysis models were used to identify risk factors for chronic lung diseases.RESULTS: Using the Third National Health and Nutrition Examination Survey, 1988-1994 (NHANES III) reference equations, the prevalence of chronic airflow obstruction (CAO) was 10%. The main risk factor was older age, 60-69 years (OR 3.16, 95% CI 1.20-8.31). Lower education, high body mass index and a history of TB were also identified as significant risk factors. The prevalence of a low forced vital capacity (FVC) using NHANES III was 62.7% (SE 2.2) and 11.3% (SE 1.4) using locally derived values.CONCLUSION: The prevalence of spirometric abnormality, mainly low FVC, was high, suggesting that CRD is of substantial public health importance in urban Sudan. Strategies for the prevention and control of these problems are needed.

Prevention and control of childhood asthma and allergy in the EU from the public health point of view: Polish Presidency of the European Union.

The leading priority for the Polish Presidency of the Council of the European Union was to reduce health inequalities across European societies, and, within its framework, prevention and control of respiratory diseases in children. This very important paper contain proposal of international cooperation on the prevention, early detection and monitoring of asthma and allergic diseases in childhood which will be undertaken by the EU member countries as a result of EU conclusion developed during the Polish Presidency of the Council of the European Union. This will result in collaboration in the field of chronic diseases, particularly respiratory diseases, together with the activity of the network of national institutions and NGOs in this area. Paper also contains extensive analysis of the socio-economic, political, epidemiological, technological and medical factors affecting the prevention and control of childhood asthma and allergy presented during Experts presidential conference organized in Warsaw-Ossa 21-22 September 2011.

Practical guide to skin prick tests in allergy to aeroallergens.

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

Forced vital capacity, airway obstruction and survival in a general population sample from the USA.

BACKGROUND: Many studies show a link between forced expiratory volume in 1 s (FEV(1)) and survival in the general population and this has been interpreted as a link between airway obstruction and survival. However, the observation that vital capacity is also associated with survival weakens this interpretation. METHODS: Data on spirometry and survival were taken from the Atherosclerosis Risk in Communities (ARIC) limited access dataset. Survival among 7489 participants with usable spirometry and complete data was regressed against measures of ventilatory function after controlling for many other factors likely to be associated with survival. RESULTS: Survival was strongly associated with forced vital capacity (FVC) after adjustment for FEV(1), but not the other way round. The fully adjusted hazard ratio (HR) associated with high FVC was 0.90 in men (95% CI 0.80 to 1.00; p=0.049) and 0.82 in women (95% CI 0.70 to 0.95; p=0.01). This compares with 0.98 for FEV(1) in men (95% CI 0.90 to 1.07; p.0.72) and 1.01 in women (95% CI 0.89 to 1.15; p=0.84). There was no association between survival and airway obstruction as measured by the FEV(1)/FVC ratio. CONCLUSIONS: FVC but not airway obstruction predicts survival in asymptomatic adults without chronic respiratory diagnoses or persistent respiratory symptoms. The association is not explained by age, anthropometry, smoking, income occupation or blood pressure. As FVC later in life, cardiovascular risk, type II diabetes mellitus and low-grade systemic inflammation are all associated with poor fetal growth, these other conditions may be partly responsible for the poor survival in those with low FVC.

Pharmacovigilance of drug allergy and hypersensitivity using the ENDA-DAHD database and the GALEN platform. The Galenda project.

Nonallergic hypersensitivity and allergic reactions are part of the many different types of adverse drug reactions (ADRs). Databases exist for the collection of ADRs. Spontaneous reporting makes up the core data-generating system of pharmacovigilance, but there is a large under-estimation of allergy/hypersensitivity drug reactions. A specific database is therefore required for drug allergy and hypersensitivity using standard operating procedures (SOPs), as the diagnosis of drug allergy/hypersensitivity is difficult and current pharmacovigilance algorithms are insufficient. Although difficult, the diagnosis of drug allergy/hypersensitivity has been standardized by the European Network for Drug Allergy (ENDA) under the aegis of the European Academy of Allergology and Clinical Immunology and SOPs have been published. Based on ENDA and Global Allergy and Asthma European Network (GA(2)LEN, EU Framework Programme 6) SOPs, a Drug Allergy and Hypersensitivity Database (DAHD((R))) has been established under FileMaker((R)) Pro 9. It is already available online in many different languages and can be accessed using a personal login. GA(2)LEN is a European network of 27 partners (16 countries) and 59 collaborating centres (26 countries), which can coordinate and implement the DAHD across Europe. The GA(2)LEN-ENDA-DAHD platform interacting with a pharmacovigilance network appears to be of great interest for the reporting of allergy/hypersensitivity ADRs in conjunction with other pharmacovigilance instruments.

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

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

[GA2LEN (Global Allergy and Asthma European Network)]. / Le réseau d'excellence de l'Union Européenne GA2LEN (Global Allergy and Asthma European Network).

Allergic diseases represent a major health problem in Europe. They are increasing in prevalence, severity and costs. GA2LEN (Global Allergy and Asthma European Network), an FP6 Network of Excellence, was created in 2005 as a vehicle to ensure excellence in research bringing together research and clinical institutions to combat fragmentation in the European research area and to tackle Allergy in its globality. GA2LEN benefited greatly from the voluntary efforts of researchers who are strongly committed to this model of pan-European collaboration. The network was organized in order to increase networking for scientific projects in allergy and asthma around Europe and to make GA2LEN the world leader in the field. Besides these activities, research has been jointly made and the first papers are being published. GA2LEN achievements in general can be grouped as those for a durable infrastructure built up during the project phase those which are project-related work based on these novel infrastructures, and the development and implementations of guidelines. The major achievements of GA2LEN are reported in this paper.

The effects of allergens in outdoor air on both atopic and nonatopic subjects with airway disease.

BACKGROUND: Reports on air pollution and asthma exacerbations have been inconsistent, although effects of airborne allergen can be spectacular. With no generalized test for allergen in air, it is not known how far allergen is responsible for nonepidemic exacerbations of the disease. METHODS: Two hundred and ninety-seven patients using bronchodilators aged 18-64 years attending a London practice provided serum samples and were asked to report any acute respiratory events over the coming months. Small particles with a mean aerodynamic diameter <10 microm (PM(10)) were collected using a high volume sampler on the roof of the practice. The ability of airborne particles to bind IgE from the patients was compared for particles sampled on the weekend before their reported exacerbation with particles sampled on the weekend 2 weeks before or after. RESULTS: Exacerbations were associated with a 25% increase in IgE binding to particles collected on the previous weekend compared with the control weekends (95% confidence interval: 10-43%; P = 0.00089). This increase was not higher in patients with positive skin tests or in those sensitized to grass or tree pollens. CONCLUSIONS: Airborne allergen is an important cause of exacerbations even in those with 'intrinsic' asthma. It is important to identify the allergens responsible, as some of these may be controllable. Interpretation of associations of asthma exacerbations with other air pollutants is difficult in the light of these findings.

Prevalence of chronic airflow limitation in Kashmir, North India: results from the BOLD study.

BACKGROUND: Data on spirometrically defined chronic airflow limitation (CAL) are scarce in developing countries. OBJECTIVE: To estimate the prevalence of spirometrically defined CAL in Kashmir, North India. METHODS: Using Burden of Obstructive Lung Disease survey methods, we administered questionnaires to randomly selected adults aged ⩾40 years. Post-bronchodilator spirometry was performed to estimate the prevalence of CAL and its relation to potential risk factors. RESULTS: Of 1100 participants initially recruited, 953 (86.9%) responded and 757 completed acceptable spirometry and questionnaires. The prevalence of a forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) ratio less than the lower limit of normal was 17.3% (4.5) in males and 14.8% (2.1) in females. Risk factors for CAL included higher age, cooking with wood and lower educational status. The prevalence of current smoking was 61% in males and 22% in females; most smoked hookahs. CAL was found equally in non-smoking males and females, and was independently associated with the use of the hookah, family history of respiratory disease and poor education. A self-reported doctor's diagnosis of chronic obstructive pulmonary disease was reported in 8.4/1000 (0.9% of females and 0.8% of males). CONCLUSION: Spirometrically confirmed CAL is highly prevalent in Indian Kashmir, and seems to be related to the high prevalence of smoking, predominantly in the form of hookah smoking.

Gaps in using bronchodilators, inhaled corticosteroids and influenza vaccine among 23 high- and low-income sites.

BACKGROUND: Increasing access to essential respiratory medicines and influenza vaccination has been a priority for over three decades. Their use remains low in low- and middle-income countries (LMICs), where little is known about factors influencing use, or about the use of influenza vaccination for preventing respiratory exacerbations. METHODS: We estimated rates of regular use of bronchodilators, inhaled corticosteroids and influenza vaccine, and predictors for use among 19 000 adults in 23 high-income countries (HICs) and LMIC sites. RESULTS: Bronchodilators, inhaled corticosteroids and influenza vaccine were used significantly more in HICs than in LMICs, after adjusting for similar clinical needs. Although they are used more commonly by people with symptomatic or severe respiratory disease, the gap between HICs and LMICs is not explained by the prevalence of chronic obstructive pulmonary disease or doctor-diagnosed asthma. Site-specific factors are likely to influence use differently. The gross national income per capita for the country is a strong predictor for use of these treatments, suggesting that economics influence under-treatment. CONCLUSION: We still need a better understanding of determinants for the low use of essential respiratory medicines and influenza vaccine in low-income settings. Identifying and addressing these more systematically could improve the access and use of effective treatments.

Serologic precursors of cancer: serum micronutrients and the subsequent risk of pancreatic cancer.

In a nested case-control study the stored, frozen sera from 22 cases of cancer of the pancreas and 44 matched control subjects were assayed for retinol, retinol-binding protein, total carotenoids, beta-carotene, lycopene, vitamin E (alpha-tocopherol), and selenium. Prediagnostic serum levels of lycopene and Se were lower among cases than among matched control subjects. These differences remained after adjustment was made for possible confounding by smoking, educational level, and the other measured serum levels. Low levels of serum vitamin E appeared to have a protective effect but a chance association between vitamin E and cancer of the pancreas could not reasonably be excluded. The association between cancer of the pancreas and serum Se was significant when the data were analyzed as a whole but its effect was seen principally in men.

On measuring repeatability of data from self-administered questionnaires.

It is usually necessary to estimate repeatability of a self-administered questionnaire from responses by subjects on just two occasions. It is shown that it is not possible to estimate false positive and false negative classification rates separately, but that an average correct classification can be calculated. This is recommended as the appropriate absolute measure of repeatability, whereas the kappa statistic, which can be interpreted as the ratio of between subject to total variation, is a measure of repeatability relative to prevalence of responses. Both measures should be calculated to give complete information on repeatability, analogous to absolute and relative measures used for continuous variables.

Adjustment of reported prevalence of respiratory symptoms for non-response in a multi-centre health survey.

BACKGROUND: Estimation of non-response bias by modelling prevalence as a function of the number of mailings required to achieve a response, or of the cumulative response, has been advocated, but the models have not incorporated age and sex, differential response rates by age and sex, or season of response. METHODS: The effect on age-sex standardized prevalence of estimating non-response bias using a variety of models was investigated using data on nine symptom and medication questions from 13,007 subjects in the three English centres of the European Community Respiratory Health Survey. Comparison was made of goodness of fit and the prediction of responses in a 25% follow-up sample with the observed values. RESULTS: Despite low response rates in Cambridge and significant decreases in prevalence with additional mailings or increasing cumulative response in Norwich, there were only small effects on estimated age-sex standardized prevalences. No model was consistently better for any centre or question. CONCLUSIONS: The models are useful for exploring the sensitivity of estimated prevalence to non-response bias, but should be used with caution to adjust estimates. Ideally first mailings should be staggered over the whole year so that mailing and season are not confounded, and sufficient mailings or other contacts carried out for the whole sample to ensure a high response rate.

What symptoms predict the bronchial response to histamine? Evaluation in a community survey of the bronchial symptoms questionnaire (1984) of the International Union Against Tuberculosis and Lung Disease.

A questionnaire developed by the International Union against Tuberculosis and Lung Disease (IUATLD) to assess bronchial symptoms has been tested for its ability to predict the bronchial response to histamine in adults aged 18-64 years living in two areas of southern England. A number of questions were found to be independently associated with increased reactivity in the first randomly selected half of the subjects. These symptoms included wheeze, waking at night with shortness of breath, tightness in the chest or shortness of breath when exposed to animals, dust or feathers and the non-specific symptom of persistent problems with breathing. A predictive score based on these symptoms was more sensitive and only slightly less specific than the question on wheeze alone in predicting the response to histamine in the second half of the subjects. Questions about asthma though more specific were considerably less sensitive than either. Symptoms did not differentiate between reactivity associated with positive skin tests and that associated with smoking.

Patterns of acute stroke care in three districts of southern England.

OBJECTIVE: To quantify the use of health care services by acutely ill stroke patients in three district health authorities. DESIGN: A follow up study of all patients recorded in population based registers who had a first ever stroke in three district health authorities, with assessment following the onset and three months after the stroke. SETTING: West Lambeth, Lewisham and North Southwark, and Tunbridge Wells District Health Authorities in south east England. SUBJECTS: All first time stroke patients under the age of 75 years who presented between 15 August 1989 and 14 August 1990. MEASUREMENTS AND MAIN RESULTS: Hospital admission rates, rates of use of rehabilitation services, and contact with medical practitioners together with assessment of disability and handicap were determined. A total of 386 strokes were registered. Seventy eight per cent were treated in hospital and younger and incontinent patients were significantly more likely to be admitted. The median stay was 21 days. Patients in West Lambeth, those paralysed, and those who stayed longer in hospital were more likely to receive physiotherapy. Altogether 265 patients were followed up, 117 having died within three months of the stroke. During the three months, 150 (57%) had seen a hospital physician and 181 (69%) their general practitioner, but 18 (7%) had seen neither. Sixty seven (26%) patients were moderately or severely disabled. Twenty seven per cent of inpatients had received no inpatient physiotherapy and 67% of all patients no outpatient physiotherapy during the three months. CONCLUSIONS: The hospital admission rates were high, with long lengths of stay. There were significant differences in the amount of rehabilitation received in each district. This was low overall, especially for those not admitted to hospital. As expected, patients admitted for long periods were the most likely to receive therapy. Before district policies for admission and management of stroke patients can be drawn up, increased knowledge of which aspects of stroke management are effective is needed. Policies should aim to provide planned, coordinated care between hospital and the community. It is striking that many patients received no form of rehabilitation therapy.

Does the incidence, severity, or case fatality of stroke vary in southern England?

STUDY OBJECTIVES: To determine differences in incidence and case fatality of stroke in district health authorities with differing standardised mortality ratios (SMR) for stroke in residents aged under 65 years in whom death from stroke is considered 'avoidable'. DESIGN: Registration of first ever strokes in three district health authorities. Patients were assessed and followed up over one year by one of three observers. SETTING: West Lambeth, Lewisham and North Southwark, and Tunbridge Wells District Health Authorities in south east England. PARTICIPANTS: Patients under the age of 75 years having a first ever in a lifetime stroke between 15 August 1989 and 14 August 1990. MEASUREMENTS AND MAIN RESULTS: Age specific incidence rates and survival time from stroke to death. Severity was assessed in terms of the level of consciousness and the presence of speech, urinary, and motor impairment within the first 24 hours of the stroke. Altogether 386 strokes were registered. There was a significant difference in the incidence rate between district health authorities in those aged under 65 (p < 0.01). The overall case fatality was 26% at three weeks with no significant difference between the districts. Poor survival was associated jointly with increased age and with coma, incontinence, and swallowing impairment in the first 24 hours after a stroke. CONCLUSIONS: The SMRs for stroke in those aged under 65 in these three health districts reflect the incidence of stroke. Case fatality at three weeks does not vary between these districts and consequently would not be a sensitive indicator of the quality of care. This also suggests that differences in services between the districts did not lead to changes in prognosis. In districts with high SMRs for stroke there is a need for further study and reduction of risk factors, thereby reducing the incidence and burden of stroke locally. This study provides a framework for assessing the needs for stroke prevention and treatment in both rural and urban areas without an elaborate protocol and detailed neurological assessment.

Respiratory effects of lowering tar and nicotine levels of cigarettes smoked by young male middle tar smokers. I. Design of a randomised controlled trial.

STUDY OBJECTIVE: The aim was to investigate the effect on respiratory health of male middle tar smokers changing the tar and nicotine levels of the cigarettes they smoke for a six month period. DESIGN: This was a randomised controlled trial. Middle tar smokers were randomly allocated to smoke one of three different types of cigarette (low tar, middle nicotine; middle tar, middle nicotine; and low tar, low nicotine) in place of their usual cigarette for a six month period. Main outcome measures were assessment of respiratory health by documenting respiratory symptoms and peak expiratory flow rates, and of nicotine inhalation by measuring the urinary excretion of nicotine metabolites. SETTING: 21 local authority districts of England. SUBJECTS: Participants were male middle tar smokers aged 18-44 years. MAIN RESULTS: Postal questionnaires were sent to 265,016 individuals selected from the electoral registers of 21 local authority districts of England; 64% of questionnaires were returned revealing 7736 men aged 18-44 years who smoked only middle tar cigarettes. Of these, 7029 (90%) were sent a health warning and 707 (10%) were not; the latter acted as a control group to assess the effect of the health warning. Of the 7029 men who had received a health warning and were visited at the recruitment stage, 2666 agreed and were eligible to participate in the trial although only 1541 (58% of those who agreed and were eligible) actually started smoking the study cigarettes; 643 men (24% of those willing to participate at the beginning of the trial and 42% of those who actually started smoking the study cigarettes) completed the trial smoking the study cigarettes. Of these, 213 were in the low tar middle nicotine group, 220 were in the middle tar middle nicotine group, and 210 were in the low tar low nicotine group. CONCLUSIONS: This study shows the feasibility of identifying and recruiting sufficient numbers of male middle tar smokers, with adequate numbers completing the trial, to detect any changes in respiratory health over a six month period.