[Allergic disease--pollen allergy and climate change]. / Allergiske sygdomme--pollenallergi og klimaaendringer.

Pollen allergy currently affects a fifth of the population. A warmer climate will lead to a longer pollen season and more days with high pollen counts. In addition, a warmer climate increases the risk of proliferation of new plants with well-known allergenic pollens like ragweed, plane tree and wall pellitory, which have not previously caused allergy in Denmark. The consequences will be more people with hay fever and pollen asthma, longer allergy seasons and an increase in the severity of symptoms, disease-related costs and demands on health care for diagnosis and treatment of more complex allergies.

Hypersensitivity to local anaesthetics--update and proposal of evaluation algorithm.

Local anaesthetics (LA) are widely used drugs. Adverse reactions are rare but may be caused by delayed-type hypersensitivity reactions and probably also immediate-type reactions. As it is not always easy to clinically differ between these subtypes, allergy skin testing should be considered. Although numerous test protocols have been published, how patients with hypersensitivity reactions to LA are ideally evaluated remains a topic of discussion. This review attempts to generate a comprehensive update on allergic reactions to LA and to present an algorithm that can be used for the evaluation of patients suspected with immediate- and delayed-type immune reactions. Literature was examined using PubMed-Medline, EMBASE, Biosis and Science Citation Index. Based on the literature, the proposed algorithm may safely and rapidly distinguish between immediate-type and delayed-type allergic immune reactions.

Disease variability in asthma: how do the patients respond?--and why?

BACKGROUND AND AIM: Asthma is a variable disease, and therapy should be tailored accordingly. The aim of this study was to explore patterns of self-management in response to disease variability in adult asthmatics. METHODS: Adult asthmatics (n = 509), recruited through a web-based panel, answered a questionnaire concerning asthma knowledge, compliance, and treatment, including specified treatment options, through the Internet. RESULTS: Two-thirds of the patients on inhaled corticosteroids (ICS) stepped-up and down their daily dose without prior contact to their doctor, and more than 50% took less ICS than prescribed during periods with fewer symptoms. In case of deterioration, 57% of the patients would only increase their reliever medication, whereas 23% would also increase their controller medication, although 59% were instructed by their doctor to do so. The self-perceived severity of asthma (graded as mild, moderate or severe) was not associated with the patients' response pattern. The preferred treatment strategy, differing primarily with regard to dosing and timing of controller medication, was associated with feeling safe about self-adjustment of controller medication (p < 0.001), but not with self-reported knowledge of asthma (p > 0.5). CONCLUSION: In case of deterioration, the majority of adult asthmatics only increase their reliever medication, although instructed by their doctors also to increase their controller medication. Furthermore, the patients' preferred strategy for management of disease variability seems not to be driven by their knowledge of the disease.

[The quality of asthma treatment in Denmark. How far are we--and how far are our patients?]. / Kvaliteten af astmabehandling i Danmark. Hvor langt er vi--og hvor langt er patienterne?

INTRODUCTION: Despite the availability of safe and effective therapies for asthma, many patients have sub-optimal asthma control. AIM: To assess the current status with regard to the treatment and monitoring of adult asthmatics and to identify factors of importance for compliance with controller therapy. MATERIALS AND METHODS: Based on information from focus group interviews, we developed a questionnaire focusing on knowledge of asthma, compliance and therapy. The participants (n = 509) answered the questionnaire over the Internet. RESULTS: Approximately 70% of patients were treated with inhaled corticosteroids (ICS), whereas 25% were only treated with a short-acting beta2-agonist, 20% of whom had severe asthma. In the preceding year, 46% of patients had their lung function measured. Up to 25% of patients stated that they forgot or deliberately decided not to take their ICS at least twice a week. The most frequent reason for non-compliance was lack of asthma symptoms. Non-compliance was associated with disagreement with the statement that ICS is an essential part of asthma therapy (p<0.002). Self-assessed asthma severity was positively associated with regular scheduled doctor visits (p<0.001) and good compliance (p<0.001). CONCLUSION: The treatment and monitoring of asthma in Denmark is not in accordance with guidelines, e.g. with regard to patient education and the use of spirometry. Non-compliance with controller therapy is frequent, and the reasons seem to be accessible through education of both patients and doctors.

Treatment and evaluation of patients with acute exacerbation of asthma before and during a visit to the ER in Denmark.

BACKGROUND: Acute exacerbation of asthma may be life-threatening and quite often results in a visit to the emergency room (ER) or admission to a hospital. The aim was to evaluate the treatment and the quality of clinical management of asthma exacerbations, and finally, to identify the factors leading to admission. MATERIAL AND METHODS: In a retrospective design, we audited the hospital records of all patients aged 18-40 years admitted to five Danish university hospitals with an acute exacerbation of asthma in 2004. RESULTS: We found records covering 323 asthmatic patients (186 women). Before admission, the mean (standard deviation) duration of the exacerbation was 5.2 (7.5) days. Of those admitted, 14% did not use any medication, 39% used inhaled corticosteroids (ICS) either with a beta(2)-agonist or alone, systemic steroids, and 34% used a beta(2)-agonist alone. Lung function (peak flow or forced expiratory volume in first second) was measured in 60% on admission, in 58% on discharge and in 47% on both occasions (P < 0.01). Temperature, heart rate and oxygen saturation were measured in 231 of the patients (72%), but the respiratory frequency rate was measured in only 16% of the patients, with some differences between the five hospitals. On discharge, 50% were treated with systemic steroids, and a further 20% had ICS prescribed (P < 0.01, admission vs discharge). In 21% of the cases, inadequate treatment was identified as the most likely reason for their ER visit/admission to a hospital. CONCLUSIONS: The assessment and treatment of patients admitted with acute asthma exacerbation was often suboptimal. Under-treatment with the anti-asthmatic medication was the main reason for admission.

Management of asthma in adults: do the patients get what they need--and want?

Suboptimal asthma control may be caused by a combination of factors, such as nonadherence to guidelines, lack of compliance, and poor asthma education. The aim was to assess patients' knowledge of asthma and different management strategies, including patients' attitudes toward involvement in treatment decisions. The participants (n=509) were recruited from all parts of Denmark through a web-based panel (Zapera Danmarkspanel). A questionnaire concerning asthma knowledge, compliance, and treatment was fulfilled through the Internet. Among the participating adult asthmatic patients, signs of uncontrolled disease with night asthma (16%), daily symptoms (18%), or exercise-induced asthma (11%) were found. Of 285 participants with persistent asthma, 70% used inhaled corticosteroids. Lung function was measured within the preceding 6 months in 24% of patients, whereas 7% had never had their lung function measured and peak flow monitoring was reported by 5%. Written action plans were provided for 12% of patients and 50% had had their inhaler technique checked. Although 59% of patients were instructed to adjust their controller therapy if needed, only 23% reported that they had done so. In conclusion, this study of adult asthmatic patients revealed an important deficit in patient education, little use of lung function measurements, and poor compliance with guidelines for asthma management. Furthermore, asthmatic patients want more education, although they do not use it when provided by their doctor, indicating that change in educational strategy is needed.

[Allergology in Denmark 2006]. / Allergologi i Danmark 2006.

Allergic diseases are prominent, possibly life threatening, and a cause of worldwide concern. Evidence-based education of doctors in the specialty of allergology is a prerequisite for correct diagnosis and treatment of patients with allergic diseases. Recently, the specialty of allergology has been abolished in Denmark, without any upgrading of the education of doctors in related specialties. As a consequence, one could fear that allergy expertise will be disappearing. We propose collaboration among experts from related specialties with joint mediation of knowledge through a centre of allergology, common educational programs for doctors in training and physician specialists, and collaboration in regional centres of allergology.

The patient's perspective: adherence or non-adherence to asthma controller therapy?

STUDY OBJECTIVE: Adherence with controller therapy poses a major challenge to the effective management of persistent asthma. The aim of this study was to explore the patient-related aspects of adherence among adult asthmatics. DESIGN AND PARTICIPANTS: The participants (n = 509 adult asthmatics), recruited from all parts of Denmark, answered the questionnaire concerning asthma knowledge, attitudes, adherence, and treatment through the Internet. RESULTS: A total of 67% of the patients were prescribed inhaled corticosteroids (ICS). However, according to Global Initiative for Asthma (GINA)-guidelines' symptom severity classification, 85% should have been on ICS. Accidental and intentional non-adherence with ICS at least twice a week was reported by 27% and 24%, respectively. In case of deterioration, 60% of the patients preferred to take more reliever medication, instead of increasing the ICS dose. Having a fixed daily routine with regard to medication and following the advice given by their doctor were the main reasons for adherence, whereas lack of perceived symptoms was the main reason for non-adherence. Non-adherence was associated with increasing disagreement with the statements that controller therapy is effective (p < 0.04), as well as an essential part of asthma therapy (p < 0.002). CONCLUSIONS: Both accidental and intentional non-adherence with controller therapy is common among adult asthmatics. The reasons for suboptimal adherence seem to be accessible through education of both patients and caregivers.

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.