ARGprofiler-a pipeline for large-scale analysis of antimicrobial resistance genes and their flanking regions in metagenomic datasets.

MOTIVATION: Analyzing metagenomic data can be highly valuable for understanding the function and distribution of antimicrobial resistance genes (ARGs). However, there is a need for standardized and reproducible workflows to ensure the comparability of studies, as the current options involve various tools and reference databases, each designed with a specific purpose in mind. RESULTS: In this work, we have created the workflow ARGprofiler to process large amounts of raw sequencing reads for studying the composition, distribution, and function of ARGs. ARGprofiler tackles the challenge of deciding which reference database to use by providing the PanRes database of 14 078 unique ARGs that combines several existing collections into one. Our pipeline is designed to not only produce abundance tables of genes and microbes but also to reconstruct the flanking regions of ARGs with ARGextender. ARGextender is a bioinformatic approach combining KMA and SPAdes to recruit reads for a targeted de novo assembly. While our aim is on ARGs, the pipeline also creates Mash sketches for fast searching and comparisons of sequencing runs. AVAILABILITY AND IMPLEMENTATION: The ARGprofiler pipeline is a Snakemake workflow that supports the reuse of metagenomic sequencing data and is easily installable and maintained at https://github.com/genomicepidemiology/ARGprofiler.

A curated data resource of 214K metagenomes for characterization of the global antimicrobial resistome.

The growing threat of antimicrobial resistance (AMR) calls for new epidemiological surveillance methods, as well as a deeper understanding of how antimicrobial resistance genes (ARGs) have been transmitted around the world. The large pool of sequencing data available in public repositories provides an excellent resource for monitoring the temporal and spatial dissemination of AMR in different ecological settings. However, only a limited number of research groups globally have the computational resources to analyze such data. We retrieved 442 Tbp of sequencing reads from 214,095 metagenomic samples from the European Nucleotide Archive (ENA) and aligned them using a uniform approach against ARGs and 16S/18S rRNA genes. Here, we present the results of this extensive computational analysis and share the counts of reads aligned. Over 6.76∙108 read fragments were assigned to ARGs and 3.21∙109 to rRNA genes, where we observed distinct differences in both the abundance of ARGs and the link between microbiome and resistome compositions across various sampling types. This collection is another step towards establishing global surveillance of AMR and can serve as a resource for further research into the environmental spread and dynamic changes of ARGs.

AI, doping and ethics: On why increasing the effectiveness of detecting doping fraud in sport may be morally wrong.

In this article, our aim is to show why increasing the effectiveness of detecting doping fraud in sport by the use of artificial intelligence (AI) may be morally wrong. The first argument in favour of this conclusion is that using AI to make a non-ideal antidoping policy even more effective can be morally wrong. Whether the increased effectiveness is morally wrong depends on whether you believe that the current antidoping system administrated by the World Anti-Doping Agency is already morally wrong. The second argument is based on the possibility of scenarios in which a more effective AI system may be morally worse than a less effective but non-AI system. We cannot, of course, conclude that the increased effectiveness of doping detection is always morally wrong. But our point is that whether the introduction of AI to increase detection of doping fraud is a moral improvement depends on the moral plausibility of the current system and the distribution of harm that will follow from false positive and false negative errors.

Dysfunctional breathing and its impact on asthma control in children and adolescents.

BACKGROUND: Dysfunctional breathing (DB) has been shown to negatively affect asthma control in adults, but for children and adolescents, the knowledge is scarce. DB is among others characterized by dyspnea and hyperventilation. The Nijmegen Questionnaire (NQ) is often used as a marker for DB. We conducted a cross-sectional survey to estimate the prevalence of DB in patients with asthma in a pediatric outpatient clinic and to determine the impact of DB on asthma control. METHODS: Patients between 10 and 17 years were invited to complete the NQ and the Asthma Control Questionnaire (ACQ) and report the use of beta2 agonist (ß2). Spirometry data and prescribed asthma medications were noted from the patient record. RESULTS: Three hundred and sixty-three patients (180 boys) completed the survey. Sixty-seven patients (18%) scored ≥23 points in the NQ predicting DB. The DB group was older (median (range)) 15.6 (10.5-17.9) vs. 13.7 (10.0-17.9) years) (p < .01), and girls were overrepresented (84%) (p < .01). FEV1% exp. was higher in the DB group (mean (SD)) (89.4 (9.0) vs. 85.7 (11.8)) (p < .02). ACQ score (median (range)) (2.0 (0-4) vs. 0.6 (0-3.4)) (p < .01) and the use of ß2 (median (range)) (2 (0-56) vs. 0 (0-20) puffs/week) (p < .01) were higher. Inhaled corticosteroid dose (mean (SD) (416 (160) vs. 420 (150) mcg) and the use of a second controller were equal between the groups. CONCLUSION: Dysfunctional breathing was a frequent comorbidity, especially in adolescent girls. DB correlated with poorer asthma control and higher use of ß2 and may be an important cofactor in difficult-to-treat asthma.

Leveling (down) the playing field: performance diminishments and fairness in sport.

The 2018 eligibility regulation for female competitors with differences of sexual development (DSD) issued by World Athletics requires competitors with DSD with blood testosterone levels at or above 5 nmol/L and sufficient androgen sensitivity to be excluded from competition in certain events unless they reduce the level of testosterone in their blood. This paper formalises and then critically assesses the fairness-based argument offered in support of this regulation by the federation. It argues that it is unclear how the biological advantage singled out by the regulation as an appropriate target for diminishment, is relevantly different from other biological advantages that athletes may enjoy, and specifically that Sigmund Loland's recent attempt to drive a wedge between heightened levels of blood testosterone and other biological advantages fails. The paper also suggests that even if heightened blood testosterone levels do differ relevantly from other types of biological advantage, the regulation is further challenged by studies indicating that athletes with blood testosterone at the high end of the normal range have a competitive advantage over athletes with blood testosterone levels at the low end of it. Finally, the paper contends that the premises of the fairness-based argument do not unequivocally support the conclusion that DSD athletes with heightened levels of testosterone should diminish those levels, since, just as powerfully, they support allowing athletes with normal levels of testosterone to use performance-enhancing drugs in the name of fairness.

Critique of autonomy-based arguments against legalising assisted dying.

The aim of this article is to present and critically investigate a type of argument against legalising assisted dying on request (ADR) for patients who are terminally ill and experiencing suffering. This type of argument has several variants. These-which we call 'autonomy-based arguments' against legalising ADR-invoke different specifications of the premise that we ought not to respect requests for assistance in dying made by terminally ill and suffering patients because the basic conditions of autonomy cannot be met in scenarios where such requests are made. Specifically, it is argued either (1) that as a result of pain, anxiety or desperation, terminally ill patients are not competent decision makers or (2) that legalisation of ADR would lead to social pressure or in other ways change the patient's context of choice in ways that make such requests nonautonomous. We argue that these types of arguments are problematic in light both of empirical studies and the fact that we usually judge that it is morally right to respect the wishes and decisions of dying people even if they suffer.

Antimicrobial resistance monitoring in the Danish swine production by phenotypic methods and metagenomics from 1999 to 2018.

BackgroundIn Denmark, antimicrobial resistance (AMR) in pigs has been monitored since 1995 by phenotypic approaches using the same indicator bacteria. Emerging methodologies, such as metagenomics, may allow novel surveillance ways.AimThis study aimed to assess the relevance of indicator bacteria (Escherichia coli and Enterococcus faecalis) for AMR surveillance in pigs, and the utility of metagenomics.MethodsWe collated existing data on AMR and antimicrobial use (AMU) from the Danish surveillance programme and performed metagenomics sequencing on caecal samples that had been collected/stored through the programme during 1999-2004 and 2015-2018. We compared phenotypic and metagenomics results regarding AMR, and the correlation of both with AMU.ResultsVia the relative abundance of AMR genes, metagenomics allowed to rank these genes as well as the AMRs they contributed to, by their level of occurrence. Across the two study periods, resistance to aminoglycosides, macrolides, tetracycline, and beta-lactams appeared prominent, while resistance to fosfomycin and quinolones appeared low. In 2015-2018 sulfonamide resistance shifted from a low occurrence category to an intermediate one. Resistance to glycopeptides consistently decreased during the entire study period. Outcomes of both phenotypic and metagenomics approaches appeared to positively correlate with AMU. Metagenomics further allowed to identify multiple time-lagged correlations between AMU and AMR, the most evident being that increased macrolide use in sow/piglets or fatteners led to increased macrolide resistance with a lag of 3-6 months.ConclusionWe validated the long-term usefulness of indicator bacteria and showed that metagenomics is a promising approach for AMR surveillance.

Company-sponsored egg freezing: an offer you can't refuse?

The aim of this article is to argue that one of the central arguments against company-sponsored non-medical egg freezing, namely that this practice is contrary to the reproductive autonomy of women, can be difficult to sustain under certain conditions. More specifically, we argue that company-sponsored egg freezing is not necessarily in conflict with the most common requirements for autonomous choice. That is, there is no reason to assume that employees cannot be adequately informed beforehand about what is scientifically known about the practice, and/or that they lack the required capacity to understand and process this information. Although they may feel a certain pressure to comply with the wishes of their employer, this concern can plausibly be alleviated through privacy regulations. In any event, such pressure is arguably not stronger than or relevantly different from other types of pressure on the labour market that most people readily accept as being ethically acceptable. Finally, we argue that company-sponsored non-medical egg freezing may mitigate certain types of oppressive socialization, although it may well perpetuate others, and should in any case arguably be dealt with through guidelines and counselling, which would ensure that women make autonomous choices when companies offer egg freezing.

Detection of mobile genetic elements associated with antibiotic resistance in Salmonella enterica using a newly developed web tool: MobileElementFinder.

OBJECTIVES: Antimicrobial resistance (AMR) in clinically relevant bacteria is a growing threat to public health globally. In these bacteria, antimicrobial resistance genes are often associated with mobile genetic elements (MGEs), which promote their mobility, enabling them to rapidly spread throughout a bacterial community. METHODS: The tool MobileElementFinder was developed to enable rapid detection of MGEs and their genetic context in assembled sequence data. MGEs are detected based on sequence similarity to a database of 4452 known elements augmented with annotation of resistance genes, virulence factors and detection of plasmids. RESULTS: MobileElementFinder was applied to analyse the mobilome of 1725 sequenced Salmonella enterica isolates of animal origin from Denmark, Germany and the USA. We found that the MGEs were seemingly conserved according to multilocus ST and not restricted to either the host or the country of origin. Moreover, we identified putative translocatable units for specific aminoglycoside, sulphonamide and tetracycline genes. Several putative composite transposons were predicted that could mobilize, among others, AMR, metal resistance and phosphodiesterase genes associated with macrophage survivability. This is, to our knowledge, the first time the phosphodiesterase-like pdeL has been found to be potentially mobilized into S. enterica. CONCLUSIONS: MobileElementFinder is a powerful tool to study the epidemiology of MGEs in a large number of genome sequences and to determine the potential for genomic plasticity of bacteria. This web service provides a convenient method of detecting MGEs in assembled sequence data. MobileElementFinder can be accessed at https://cge.cbs.dtu.dk/services/MobileElementFinder/.

Clinical prognostic factors in pleural mesothelioma: best supportive care and anti-tumor treatments in a real-life setting.

BACKGROUND: This study aims to investigate patient- and disease characteristics associated with survival in malignant pleural mesothelioma (MPM) patients with anti-tumor treatment or with best supportive care (BSC). MATERIALS AND METHODS: Consecutive MPM cases diagnosed in North Denmark Region from 1972 to 2015 were reevaluated and verified by two pathologists using modern immunohistochemical techniques. Danish registries and hospital records were used to gather patient-, asbestos exposure-, and disease information. RESULTS: Of the 279 patients, anti-tumor treatment was administered to 184 patients (66.0%). All of those received chemotherapy alone or as part of a multimodal treatment, where pemetrexed was given to 126 (68.5%) patients. Asbestos exposure was documented in 92.5% of all patients. In the treated group, mean age was lower (66 years versus 74 years, p < 0.01), rate of occupational asbestos exposure was higher (74.5 versus 54.7%, p < 0.01), more patients had better performance score (98.4 versus 60%, p < 0.01) and stage was lower (81 versus 63.2%, p < 0.01) compared to the BSC group. Multivariate analysis showed that epithelioid subtype was the only common prognostic factor for OS in both groups. In BSC patients, good PS and female gender was associated with improved OS. Median overall survival (OS) was 17 versus 4 months (p < 0.01), and independently of the histopathological subtype, the median and 2-year survival was higher in the treated versus the BSC group (p < 0.02). CONCLUSIONS: This retrospective study showed that epithelioid subtype is the only independent positive prognostic factor of survival in treated patients with MPM. For BSC patients, the epithelioid subtype, good PS, and female gender were positive prognostic factors, while age and comorbidities were not significant. This study with long-term follow-up of treated and BSC MPM patients can contribute to the clinical stratification of patients. Further validation is appropriate to verify these findings.

Doping, fairness, and unequal responsiveness: A response to Lavazza.

In a thought-provoking article in Bioethics, Andrea Lavazza defends the view that for reasons of fairness, those who cannot benefit from the use of performance-enhancing methods such as transcranial direct current stimulation (tDCS) should receive compensation for their inability. First, we argue that Lavazza's proposal to compensate athletes who are non-responsive to tDCS is practically unfeasible. Second, the compensation principle-which he appeals to in his defense of his compensation scheme-is false, as it is incoherent to focus only on the compensation of athletes who respond less well to tDCS, and not to compensate athletes who respond less well to all other types of enhancers such as mental training and food supplements.

Tenuazonic acid from Stemphylium loti inhibits the plant plasma membrane H+ -ATPase by a mechanism involving the C-terminal regulatory domain.

Pathogenic fungi often target the plant plasma membrane (PM) H+ -ATPase during infection. To identify pathogenic compounds targeting plant H+ -ATPases, we screened extracts from 10 Stemphylium species for their effect on H+ -ATPase activity. We identified Stemphylium loti extracts as potential H+ -ATPase inhibitors, and through chemical separation and analysis, tenuazonic acid (TeA) as a potent H+ -ATPase inhibitor. By assaying ATP hydrolysis and H+ pumping, we confirmed TeA as a H+ -ATPase inhibitor both in vitro and in vivo. To visualize in planta inhibition of the H+ -ATPase, we treated pH-sensing Arabidopsis thaliana seedlings with TeA and quantified apoplastic alkalization. TeA affected both ATPase hydrolysis and H+ pumping, supporting a direct effect on the H+ -ATPase. We demonstrated apoplastic alkalization of A. thaliana seedlings after short-term TeA treatment, indicating that TeA effectively inhibits plant PM H+ -ATPase in planta. TeA-induced inhibition was highly dependent on the regulatory C-terminal domain of the plant H+ -ATPase. Stemphylium loti is a phytopathogenic fungus. Inhibiting the plant PM H+ -ATPase results in membrane potential depolarization and eventually necrosis. The corresponding fungal H+ -ATPase, PMA1, is less affected by TeA when comparing native preparations. Fungi are thus able to target an essential plant enzyme without causing self-toxicity.

High flow nasal cannula and continuous positive airway pressure therapy in treatment of viral bronchiolitis: a randomized clinical trial.

Continuous positive airway pressure (CPAP) has been used in infants with bronchiolitis for decades. Recently, high flow nasal cannula (HFNC) therapy was introduced. We conducted a trial of 50 children with bronchiolitis who were randomized to treatment with CPAP or HFNC. Objectives were to compare the development in respiratory rate, pCO2, and Modified Woods Clinical Asthma Score (M-WCAS) in young children with bronchiolitis, treated with CPAP or HFNC. Secondarily, to compare Neonatal Infant Pain Score (NIPS), treatment duration, treatment failure, and hospitalization length. Median age at inclusion was 2.8 (CPAP group) vs 2.1 months (HFNC group). Mean baseline pCO2 was 6.7 in both groups and mean respiratory rate was 60 vs 56 in the CPAP and HFNC group respectively. No differences were observed in development of respiratory rate, pCO2, or M-WCAS. NIPS was higher in the CPAP group. Treatment failure was scarce in both groups. No significant differences in treatment duration or length of hospitalization were observed.Conclusion: In infants and young children with bronchiolitis, HFNC may be an effective and pleasant alternative to CPAP. Larger multicenter studies are needed to further explore differences in treatment failure and treatment duration.Trial registration: www.clinicaltrial.gov. id NCT02618213, registration date December 1, 2015.What is Known:• CPAP has been used for many years for respiratory support in infant bronchiolitis. The method requires special staff skills and may be stressful to the child.• HFNC has been introduced as a newer tool.What is New:• In infants with bronchiolitis, HFNC and CPAP were comparable in decreasing respiratory rate, pCO2, and need for oxygen supply.• Pain score during therapy was lower in the HFNC group.

Arguments on thin ice: on non-medical egg freezing and individualisation arguments.

The aim of this article is to provide a systematic reconstruction and critique of what is taken to be a central ethical concern against the use of non-medical egg freezing (NMEF). The concern can be captured in what we can call the individualisation argument. The argument states, very roughly, that women should not use NMEF as it is an individualistic and morally problematic solution to the social problems that women face, for instance, in the labour market. Instead of allowing or expecting women to deal with them on an individual level, we should address them by challenging the patriarchal structures of the labour market-for example, by securing equal pay, or paid maternal leave, or 'paid paternal [partner] leave and sick leave and affordable child care'. It will be made clear that there are several versions of this argument. The author will try to elaborate this claim, and it will be explained that the differences depend on the way in which bioethicists believe that individuals use of NMEF is morally problematic, compared with the alternative of securing social change for women in, say, the labour market. Finally, a critical discussion of three versions of the individualisation argument will follow, and it will be shown why all versions are on rather thin ice, or in other words, that they are implausible.

Age change, official age and fairness in health.

In a recent JME article, Joona Räsänen makes the case for allowing legal age change. We identify three problems with his argument and, on that basis, propose an improved version thereof. Unfortunately, even the improved argument is vulnerable to the objection that chronological age is a better proxy for justice in health than both legal and what we shall call official age.

Mesenchymal stromal cell-derived exosomes improve mitochondrial health in pulmonary arterial hypertension.

Secreted exosomes are bioactive particles that elicit profound responses in target cells. Using targeted metabolomics and global microarray analysis, we identified a role of exosomes in promoting mitochondrial function in the context of pulmonary arterial hypertension (PAH). Whereas chronic hypoxia results in a glycolytic shift in pulmonary artery smooth muscle cells (PASMCs), exosomes restore energy balance and improve O2 consumption. These results were confirmed in a hypoxia-induced mouse model and a semaxanib/hypoxia rat model of PAH wherein exosomes improved the mitochondrial dysfunction associated with disease. Importantly, exosome exposure increased PASMC expression of pyruvate dehydrogenase (PDH) and glutamate dehydrogenase 1 (GLUD1), linking exosome treatment to the TCA cycle. Furthermore, we show that although prolonged hypoxia induced sirtuin 4 expression, an upstream inhibitor of both GLUD1 and PDH, exosomes reduced its expression. These data provide direct evidence of an exosome-mediated improvement in mitochondrial function and contribute new insights into the therapeutic potential of exosomes in PAH.

Community-based football in men with prostate cancer: 1-year follow-up on a pragmatic, multicentre randomised controlled trial.

BACKGROUND: Physical exercise has been shown to be effective in relation to fatigue, aerobic fitness, and lower body strength in men with prostate cancer. However, research into the clinically relevant effects of interventions conducted in heterogeneous patient populations and in real-life clinical practice settings is warranted. METHODS AND FINDINGS: We conducted a pragmatic, multicentre, parallel randomised controlled trial in 5 Danish urological departments. Recruitment began in May 2015, the first participant was randomised in June 2015, and the last participant was included in February 2017. In total, 214 men with prostate cancer were randomly assigned to either 6 months of free-of-charge football training twice weekly at a local club (football group [FG]) (n = 109) or usual care (usual care group [UG]) (n = 105), including brief information on physical activity recommendations at randomisation. Participants were on average 68.4 (SD 6.2) years old, 157 (73%) were retired, 87 (41%) were on castration-based treatment, 19 (9%) had received chemotherapy, and 41 (19%) had skeletal metastases at baseline. In this 1-year follow-up study, we evaluated the effects of community-based football training on the following outcomes: primary outcome, quality of life; secondary outcomes: continuation of football after 6 months, hip and lumbar spine bone mineral density (BMD), mental health score, fat and lean body mass, and safety outcomes, i.e., fractures, falls, and hospital admissions. Intention to treat (ITT) and per protocol (PP) analyses were conducted. No statistically significant between-group difference was observed in change in prostate-cancer-specific quality of life (ITT: 1.9 points [95% CI -1.9 to 5.8], p = 0.325; PP: 3.6 points [95% CI -0.9 to 8.2], p = 0.119). A statistically significant between-group difference was observed in change in total hip BMD, in favour of FG (0.007 g/cm2 [95% CI 0.004 to 0.013], p = 0.037). No differences were observed in change in lumbar spine BMD or lean body mass. Among patients allocated to football, 59% chose to continue playing football after the end of the 6-month intervention period. At 1-year follow-up in the PP population, FG participants had more improvement on the Mental Component Summary (2.9 [95% CI 0.0 to 5.7], p = 0.048 points higher) than UG participants, as well as a greater loss of fat mass (-0.9 kg [95% CI -1.7 to -0.1], p = 0.029). There were no differences between groups in relation to fractures or falls. Hospital admissions were more frequent in UG compared to FG (33 versus 20; the odds ratio based on PP analysis was 0.34 for FG compared to UG). There were 3 deaths in FG and 4 in UG. Main limitations of the study were the physically active control group and assessment of physical activity by means of self-report. CONCLUSIONS: In this trial, participants allocated to football appeared to have improved hip BMD and fewer hospital admissions. Men who played football more than once a week for 1 year lost fat mass and reported improved mental health. Community-based football proved to be acceptable, even when club membership was not subsidised. TRIAL REGISTRATION: ClinicalTrials.gov NCT02430792.

Proficiency Testing of Virus Diagnostics Based on Bioinformatics Analysis of Simulated In Silico High-Throughput Sequencing Data Sets.

Quality management and independent assessment of high-throughput sequencing-based virus diagnostics have not yet been established as a mandatory approach for ensuring comparable results. The sensitivity and specificity of viral high-throughput sequence data analysis are highly affected by bioinformatics processing using publicly available and custom tools and databases and thus differ widely between individuals and institutions. Here we present the results of the COMPARE [Collaborative Management Platform for Detection and Analyses of (Re-)emerging and Foodborne Outbreaks in Europe] in silico virus proficiency test. An artificial, simulated in silico data set of Illumina HiSeq sequences was provided to 13 different European institutes for bioinformatics analysis to identify viral pathogens in high-throughput sequence data. Comparison of the participants' analyses shows that the use of different tools, programs, and databases for bioinformatics analyses can impact the correct identification of viral sequences from a simple data set. The identification of slightly mutated and highly divergent virus genomes has been shown to be most challenging. Furthermore, the interpretation of the results, together with a fictitious case report, by the participants showed that in addition to the bioinformatics analysis, the virological evaluation of the results can be important in clinical settings. External quality assessment and proficiency testing should become an important part of validating high-throughput sequencing-based virus diagnostics and could improve the harmonization, comparability, and reproducibility of results. There is a need for the establishment of international proficiency testing, like that established for conventional laboratory tests such as PCR, for bioinformatics pipelines and the interpretation of such results.

Results from the 5-year SQ grass sublingual immunotherapy tablet asthma prevention (GAP) trial in children with grass pollen allergy.

BACKGROUND: Allergy immunotherapy targets the immunological cause of allergic rhinoconjunctivitis and allergic asthma and has the potential to alter the natural course of allergic disease. OBJECTIVE: The primary objective was to investigate the effect of the SQ grass sublingual immunotherapy tablet compared with placebo on the risk of developing asthma. METHODS: A total of 812 children (5-12 years), with a clinically relevant history of grass pollen allergic rhinoconjunctivitis and no medical history or signs of asthma, were included in the randomized, double-blind, placebo-controlled trial, comprising 3 years of treatment and 2 years of follow-up. RESULTS: There was no difference in time to onset of asthma, defined by prespecified asthma criteria relying on documented reversible impairment of lung function (primary endpoint). Treatment with the SQ grass sublingual immunotherapy tablet significantly reduced the risk of experiencing asthma symptoms or using asthma medication at the end of trial (odds ratio = 0.66, P < .036), during the 2-year posttreatment follow-up, and during the entire 5-year trial period. Also, grass allergic rhinoconjunctivitis symptoms were 22% to 30% reduced (P < .005 for all 5 years). At the end of the trial, the use of allergic rhinoconjunctivitis pharmacotherapy was significantly less (27% relative difference to placebo, P < .001). Total IgE, grass pollen-specific IgE, and skin prick test reactivity to grass pollen were all reduced compared to placebo. CONCLUSIONS: Treatment with the SQ grass sublingual immunotherapy tablet reduced the risk of experiencing asthma symptoms and using asthma medication, and had a positive, long-term clinical effect on rhinoconjunctivitis symptoms and medication use but did not show an effect on the time to onset of asthma.