Asthma control in Europe: a real-world evaluation based on an international population-based study.

BACKGROUND: Epidemiologic evidence related to asthma control in patients from the general population is scanty. OBJECTIVES: We sought to assess asthma control in several European centers according to the Global Initiative for Asthma (GINA) guidelines and to investigate its determinants. METHODS: In the European Community Respiratory Health Survey II (1999-2002), 1241 adults with asthma were identified and classified into inhaled corticosteroid (ICS) users and non-ICS users in the last year. Control was assessed in both groups by using the GINA proposal (controlled, partly controlled, and uncontrolled asthma), and it was related to potential determinants. RESULTS: Only 15% (95% CI, 12% to 19%) of subjects who had used ICSs in the last year and 45% (95% CI, 41% to 50%) of non-ICS users had their asthma under control; individuals with uncontrolled asthma accounted for 49% (95% CI, 44% to 53%) and 18% (95% CI, 15% to 21%), respectively. Among ICS users, the prevalence of uncontrolled asthma showed great variability across Europe, ranging from 20% (95% CI, 7% to 41%; Iceland) to 67% (95% CI, 35% to 90%; Italy). Overweight status, chronic cough and phlegm, and sensitization to Cladosporium species were associated with poor control in ICS users. About 65% and 87% of ICS users with uncontrolled and partly controlled asthma, respectively, were on a medication regimen that was less than recommended by the GINA guidelines. CONCLUSION: Six of 7 European asthmatic adults using ICSs in the last year did not achieve good disease control. The large majority of subjects with poorly controlled asthma were using antiasthma drugs in a suboptimal way. A wide variability in asthma control emerged across Europe. CLINICAL IMPLICATIONS: Greater attention should be paid to asthma management and to the implementation of the GINA guidelines.

Incidence of chronic obstructive pulmonary disease in a cohort of young adults according to the presence of chronic cough and phlegm.

RATIONALE: The few prospective studies aimed at assessing the incidence of chronic obstructive pulmonary disease (COPD) in relation to the presence of chronic cough/phlegm have produced contrasting results. OBJECTIVES: To assess the incidence of COPD in a cohort of young adults and to test whether chronic cough/phlegm and dyspnea are independent predictors of COPD. METHODS: An international cohort of 5,002 subjects without asthma (ages 20-44 yr) with normal lung function (FEV(1)/FVC ratio >/= 70%) from 12 countries was followed from 1991-2002 in the frame of the European Community Respiratory Health Survey II. Incident cases of COPD were those who had an FEV(1)/FVC ratio less than 70% at the end of the follow-up, but did not report having had a doctor diagnose asthma during the follow-up. MAIN RESULTS: The incidence rate of COPD was 2.8 cases/1,000/yr (95% confidence interval [CI], 2.3-3.3). Chronic cough/phlegm was an independent and statistically significant predictor of COPD (incidence rate ratio [IRR], 1.85; 95% CI, 1.17-2.93) after adjusting for smoking habits and other potential confounders, whereas dyspnea was not associated with the disease (IRR = 0.98; 95% CI, 0.64-1.50). Subjects who reported chronic cough/phlegm both at baseline and at the follow-up had a nearly threefold-increased risk of developing COPD with respect to asymptomatic subjects (IRR = 2.88; 95% CI, 1.44-5.79). CONCLUSIONS: The incidence of COPD is substantial even in young adults. The presence of chronic cough/phlegm identifies a subgroup of subjects with a high risk of developing COPD, independently of smoking habits.

Factors affecting adherence to asthma treatment in an international cohort of young and middle-aged adults.

BACKGROUND: A major reason of the poor control of asthma is that patients fail to adhere to their treatment. The aim of the study was to identify factors affecting changes in asthma treatment adherence in an international cohort. METHODS: A follow-up study was carried out by means of a structured clinical interview in 971 subjects with asthma from 12 countries who participated in both the European Community Respiratory Health Survey: ECRHS-I (1990-94) and ECRHS-II (1998-2002). Subjects were considered adherent if they reported they normally took all the prescribed drugs. A logistic model was used to study the adjusted effect of the determinants. RESULTS: The net change in adherence to anti-asthmatic treatment per 10 years of follow-up was -2% (95% CI: -9.5, 5.5), 7.5% (-2.6, 17.6), 15.0% (6.6, 23.5) and 19.8% (4.1, 35.5), respectively, in Nordic, Mediterranean, Continental and extra-European areas. Among the 428 non-adherent subjects in ECRHS-I, having regular consultations with health care professionals was the strongest predictor of increased adherence (OR 3.32; 95% CI: 1.08-10.17). Among the 543 adherent subjects in ECRHS-I, using inhaled corticosteroids significantly predicted a persistence of adherence (OR 2.04; 95% CI: 1.11-3.75). No effect of gender, age, duration of the disease, smoking habit and educational level was observed. CONCLUSIONS: Our findings highlight the key role of doctors and nurses in educating and regularly reviewing the patients and support the efforts for an improvement of clinical communication.

Change in prevalence of IgE sensitization and mean total IgE with age and cohort.

BACKGROUND: Cross-sectional studies show that the prevalence of IgE sensitization is lower in older age groups than younger age groups. This could reflect either a decrease in sensitization with aging or a higher prevalence of sensitization in more recent birth cohorts. OBJECTIVE: To assess change in IgE sensitization and mean total IgE in young adults as they age. METHODS: Serum specific IgE to common allergens and total IgE were measured on 2 occasions about 9 years apart in 6371 young adults living in 28 centers, mainly in Western Europe, who took part in the European Community Respiratory Health Survey II. Outcomes were analyzed by using generalized estimating equations, and adjustments were made for differences between laboratory measures on the 2 occasions. RESULTS: Overall, there was no net change in the prevalence of sensitization to at least 1 of house dust mite, grass, or cat (net change per 10 years of follow-up, -0.1%; 95% CI, -1.7% to 1.5%), although there was a fall in mean total IgE (ratio of geometric mean total IgE, 0.86; 95% CI, 0.79 to 0.93). There was evidence that sensitization to at least 1 allergen was higher in more recent cohorts, and this was largely explained by a higher prevalence of sensitization to grass. CONCLUSION: The disease burden associated with IgE sensitization in adults, and particularly with IgE sensitization to grass, is likely to continue to increase for some time despite current evidence that the increase in allergy seen in children may have ceased.

Occupational exposure among bakery workers: impact on the occurrence of work-related symptoms as compared with allergic characteristics.

OBJECTIVE: The aim of the study is to examine the relationship between exposure to occupational allergens, sensitization, and atopy and several outcome variables and the independent associations of these interrelated risk factors to work-related symptoms in particular. METHODS: Data were collected by questionnaire, skin prick tests, lung function tests, and exposure measurements among 246 workers from 74 bakeries and analyzed using logistic and linear regression analyses. RESULTS: Exposure levels were associated with respiratory symptoms, sensitization to baker's allergens, and lung function. High exposure and sensitization to common and bakers' allergens were independent risk factors for work-related symptoms. However, allergy determinants performed best in predicting work-related symptoms. CONCLUSIONS: Current exposure to occupational allergens is a risk factor for work-related symptoms, but sensitization to occupational allergens and atopy are more adequate and easier obtainable predictors of work-related symptoms.

Smoking cessation, lung function, and weight gain: a follow-up study.

BACKGROUND: Only one population-based study in one country has reported effects of smoking cessation and weight change on lung function, and none has reported the net effect. We estimated the net benefit of smoking cessation, and the independent effects of smoking and weight change on change in ventilatory lung function in the international European Community Respiratory Health Survey. METHODS: 6654 participants in 27 centres had lung function measured in 1991-93, when aged 20-44 years, and in 1998-2002. Smoking information was obtained from detailed questionnaires. Changes in lung function were analysed by change in smoking and weight, adjusted for age and height, in men and women separately and together with interaction terms. FINDINGS: Compared with those who had never smoked, decline in FEV1 was lower in male sustained quitters (mean difference 5.4 mL per year, 95% CI 1.7 to 9.1) and those who quit between surveys (2.5 mL, -1.9 to 7.0), and greater in smokers (-4.8 mL, -7.9 to -1.6). In women, estimates were 1.3 mL per year (-1.5 to 4.1), 2.8 mL (-0.8 to 6.3) and -5.1 mL (-7.5 to -2.8), respectively. These sex differences were not significant. FEV1 changed by -11.5 mL (-13.3 to -9.6) per kg weight gained in men, and by -3.7 mL per kg (-5.0 to -2.5) in women, which diminished the benefit of quitting by 38% in men, and by 17% in women. INTERPRETATION: Smoking cessation is beneficial for lung function, but maximum benefit needs control of weight gain, especially in men.

Exercise-induced respiratory symptoms are poor predictors of bronchoconstriction.

Exercise-induced asthma (EIA) is a possible cause of poor physical performance in children. No data are available on the value of respiratory symptoms to discriminate children with bad physical fitness from children with EIA. We evaluated respiratory symptoms in school-age children during and after exercise in relation to EIA. The population of 149 primary schools (849 classes with 15,241 children) was enrolled in the study. EIB was assessed using the 6-min free-running-test (6MFRT) in 15,241 children. At the end or at premature arrest of the 6MFRT, signs reported by the children and clinical symptoms observed by supervising physicians were recorded. Peak flow measurements were obtained before and 5 and 10 min after the 6MFRT, a decrease of 15% or more being defined as significant. The 6MFRT was positive in 7.4% of primary schoolchildren. Girls were more likely to have a positive test than boys (8.5% vs. 6.4%, P < 0.001), and children living in urban areas more than those living in rural areas (8.9% vs. 7.0%, P < 0.01). Premature arrest was seen in 3.5% (i.e., n = 353) of the children. The main reasons for premature arrest were dyspnea and chest pain. Among them, only 21% had a positive 6MFRT, while 89% with a positive 6MFRT could terminate the test. Premature arrest, breathlessness, chest tightness, wheezing, and cough had a positive predictive value to detect a EIA of 21.9%, 20.8%, 36.4%, 41.2%, and 28.3%, respectively, and a sensitivity of 10.8%, 29.5%, 14.9%, 4.8%, and 13.0%, respectively. In conclusion, EIA was detected in 7.4% of schoolchildren. A slightly higher incidence was observed in girls and children from an urban area. Neither premature arrest nor clinical signs and symptoms were good predictors of EIA in primary schoolchildren.

Gender differences in the management and experience of Chronic Obstructive Pulmonary Disease.

Whether women receive the same medical care for COPD as men and if they are at risk of different outcomes as a result, is not known. The Confronting COPD International Survey was performed in the USA, Canada, France, Italy, Germany, The Netherlands, Spain and the UK in 2000 with 3265 COPD participants. Forty-one per cent were women; mean age in women and men was 61.2 (SD 10.5) and 64.4 (11.0) years, mean pack-years of smoking 36 (29) and 46 (35) years, respectively. After adjusting for age, pack-years, country and severe dyspnea (MRC scores 5 and 4), women were less likely to have had spirometry (OR 0.84, 95% C.I. 0.72-0.98) but more likely to get smoking cessation advice (OR 1.57, 1.33-1.86). Despite significantly lower pack-years of smoking, women were more likely to report severe dyspnea than men (OR 1.30, 1.10-1.54), with similar cough (OR 1.08, 0.92-1.27) and less sputum (OR 0.84, 0.72-0.98). There were no differences in the risk of hospitalisation or emergency room visit. This study indicates that gender differences in COPD care and outcomes exist.

Worldwide severity and control of asthma in children and adults: the global asthma insights and reality surveys.

BACKGROUND: In 1995, the Global Initiative for Asthma (GINA) guidelines recommended goals for the management of asthma, which were updated in 2002. However, there are no recent international surveys on the real management of asthma. OBJECTIVE: The Asthma Insights and Reality surveys are the first large-scale surveys aimed at determining international variations in the severity, control, and management of asthma in children and adults. METHODS: A cross-section of households in 29 countries in North America, Europe, and Asia were surveyed to identify from the general population asthmatic patients with symptoms within the last year or who were taking current asthma medication. A standard questionnaire was administered to 7786 adults, and, through a proxy, to 3153 children with asthma. Objective and subjective patient perception of asthma control and severity were assessed, including access to medical care, health care use, missed work-school, and medication use. RESULTS: Despite variations at a country level, a substantial effect of asthma on patients' lives was observed, with considerable loss of schooldays and workdays. The current level of asthma control worldwide falls far short of the goals for long-term management in international guidelines. A significant proportion of patients continue to have symptoms and lifestyle restrictions and to require emergency care. The proportion of adult asthmatic patients who were current smokers was also high. However, the use of anti-inflammatory preventative medication, even in patients with severe persistent asthma, was low, ranging from 26% in Western Europe to 9% in Japan, as was the use of objective lung function testing. The correlation between self-perceived severity of asthma and objective assessment of severity on the basis of GINA criteria was consistently poor in all areas. CONCLUSION: We conclude that there is direct evidence for suboptimal asthma control in many patients worldwide, despite the availability of effective therapies, with long-term management falling far short of the goals set in the GINA guidelines.

Predictors of poor asthma control in European adults.

Asthmatics in the community suffer morbidity due to poor asthma control. The Global Initiative for Asthma (GINA) guidelines established minimum goals for the management of asthma. Our objective was to quantify the demographic and clinical factors associated with asthma control in adult asthmatics. A population sample of asthmatics 16 years and older was obtained by random digit dialing in seven European countries (France, Germany, Italy, The Netherlands, Spain, Sweden, and United Kingdom), and asthma control was quantified according to daytime and nighttime symptoms, severe episodes, and limits on daily activities due to asthma. Among the 2050 adult current asthmatics surveyed, 35% had good asthma control (0 or 1 GINA goals failed), 40% had moderate asthma control (2 or 3 GINA goals failed), and 25% had poor asthma control (4 or 5 GINA goals failed). Fewer subjects with poor than those with good asthma control had ever received a lung function test, and significantly fewer patients with poor asthma control had been taught by a doctor or nurse how to use their peak flow meter. When questioned about the underlying cause of asthma, only 7.8% of asthmatics mentioned airway inflammation, and only 17.6% stated that inhaled corticosteroids were the most effective medication for reducing airway inflammation. There was more use of quick relief bronchodilator medications in the past 4 weeks among patients with poor asthma control. Asthma management practices and the knowledge, attitudes, and behavior of adult asthmatics in the general population are associated with the degree of asthma control.

Allergic sensitization, symptoms, and lung function among bakery workers as compared with a nonexposed work population.

Only few studies have assessed relative risks on occupational asthma and allergy among bakery workers, and none of them have included respiratory and work-related symptoms as well as sensitization to occupational allergens and pulmonary function. A random sample of 246 workers from traditional and industrial bakeries in two regions of Belgium were compared with a reference population of 251 workers from a petrochemical plant in the same region. Data on skin test positivity, symptoms, and lung function were collected by standardized procedures. Differences between the two subpopulations were analyzed using multiple logistic and linear regression analyses. On average, bakery workers did not more often have skin test positivity than reference workers (39.4% and 42.6%, respectively). However, bakery workers had a strongly increased risk of sensitization to specific bakery allergens (OR 22.0, 95% CI = 6.3-77.1.), whereas their risks of positive skin tests to common allergens, including wheat pollen and storage mite, were significantly decreased (OR 0.6, 95% CI = 0.4-0.9). Bakery workers had significantly more often respiratory and work-related symptoms. Accordingly, they had lower lung function parameters. Atopy and sensitization to bakers' allergens were independent and additional risk factors for work-related symptoms. Bakery workers are at increased risk of respiratory and allergic symptoms and skin test reactivity to specific bakers' allergens wheat flour and alpha-amylase. Wheat pollen and storage mite should not be regarded as baker's allergens. Nevertheless, pulmonary function of bakery workers can be characterized as mild airway obstruction only.

PM2.5 assessment in 21 European study centers of ECRHS II: Method and first winter results.

The follow-up of a cohort of adults from 29 European centers of the former European Community Respiratory Health Survey (ECRHS) I (1989-1992) will examine the long-term effects of exposure to ambient air pollution on the incidence, course, and prognosis of respiratory diseases, in particular asthma and decline in lung function. The purpose of this article is to describe the methodology and the European-wide quality control program for the collection of particles with 50% cut-off size of 2.5 microm aerodynamic diameter (PM2.5) in the ECRHS II and to present the PM2.5 results from the winter period 2000-2001. Because PM2.5 is not routinely monitored in Europe, we measured PM2.5 mass concentrations in 21 participating centers to estimate background exposure in these cities. A standardized protocol was developed using identical equipment in each center (U.S. Environmental Protection Agency Well Impactor Ninety-Six [WINS] and PQ167 from BGI, Inc.). Filters were weighed in a single central laboratory. Sampling was conducted for 7 days per month for a year. Winter mean PM2.5 mass concentrations (November 2000-February 2001) varied substantially, with Iceland reporting the lowest value (5 microg/m3) and northern Italy the highest (69 microg/m3). A standardized procedure appropriate for PM2.5 exposure assessment in a multicenter study was developed. We expect ECRHS II to have sufficient variation in exposure to assess long-term effects of air pollution in this cohort. Any bias caused by variation in the characteristics of the chosen monitoring location (e.g., proximity to traffic sources) will be addressed in later analyses. Given the homogenous spatial distribution of PM2.5, however, concentrations measured near traffic are not expected to differ substantially from those measured at urban background sites.

Factors affecting adherence to asthma treatment: patient and physician perspectives.

AIMS: To identify important factors affecting treatment adherence of patients with asthma and to summarise this information as a guide for physicians. METHODS: Information from literature and interviews with 12 respiratory physicians (four each from France, Spain and UK) and 46 asthma patients was obtained. Factors affecting adherence to asthma treatment were identified, reviewed and a flow chart developed to indicate the relationship between key factors. RESULTS: Major factors influencing adherence included: the patient-physician relationship; the patient's understanding of the disease and its treatment; the patient's beliefs and perception of the disease and its treatment, and, importantly, the patient's willingness to take an active part in his/her asthma management. CONCLUSION: Patient adherence to asthma can be improved, and the likelihood of treatment success increased, by paying attention to the factors that influence patients' willingness to participate in their treatment.

Respiratory symptoms and nocturnal gastroesophageal reflux: a population-based study of young adults in three European countries.

STUDY OBJECTIVE: To estimate the possible association between reported symptoms of gastroesophageal reflux (GER) after bedtime, sleep-disordered breathing, respiratory symptoms, and asthma. DESIGN: Cross-sectional international population survey. PARTICIPANTS: Participants consisted of 2,661 subjects (age range, 20 to 48 years) from three countries (Iceland, Belgium, and Sweden), of whom 2,202 were randomly selected from the general population and 459 were added because of reported asthma. MEASUREMENTS: The investigation included a structured interview, spirometry, methacholine challenge, peak flow diary, skin-prick tests, and a questionnaire on sleep disturbances. RESULTS: In the random population sample, 101 subjects (4.6%) reported GER, which was defined as the occurrence of heartburn or belching after going to bed at least once per week. Subjects with nocturnal GER more often were overweight and had symptoms of sleep-disordered breathing than participants not reporting GER. Participants with GER were more likely to report wheezing (adjusted odds ratio [OR], 2.5), breathlessness at rest (adjusted OR, 2.8), and nocturnal breathlessness (adjusted OR, 2.9), and they had increased peak flow variability compared to the subjects without GER. Physician-diagnosed current asthma was reported by 9% of subjects with GER compared to 4% of those not reporting GER (p < 0.05). Subjects with the combination of asthma and GER had a higher prevalence of nocturnal cough, morning phlegm, sleep-related symptoms, and higher peak flow variability than subjects with asthma alone. CONCLUSION: The occurrence of GER after bedtime is strongly associated with both asthma and respiratory symptoms, as well as symptoms of obstructive sleep apnea syndrome. The partial narrowing or occlusion of the upper airway during sleep, followed by an increase in intrathoracic pressure, might predispose the patient to nocturnal GER and, consequently, to respiratory symptoms.