European Community Respiratory Health Survey in Adults (ECRHS)

The European Community Respiratory Health Survey (ECRHS) was the first study to assess the geographical variation in asthma, allergy, and allergic sensitization in adults using the same instruments and definitions. The database of the ECRHS includes information from approximately 140 000 individuals aged 20 - 44 years from 22 countries. The aim of this review is to summarize the results of the ECRHS and to present the specific contribution of the German centers in Hamburg and Erfurt. The prevalence ranged from 2.0 - 11.9 % for asthma, 9.5 - 40.9 % for allergic rhinitis, 4.0 - 32.0 % for wheeze, 3.4 - 27.9 % for bronchial hyperreactivity, and 16.2 - 44.5 % for allergic sensitisation against common aeroallergens. Although the prevalence of these atopic disorders were found to be consistently higher for the Hamburg center compared to the Erfurt center, strong regional differences in the prevalences were also found within several other European countries. Overall Europe, the lowest prevalences were seen in the Eastern and Middle European countries with the center Erfurt, followed by the Mediterranean region. The highest prevalences were reported for all English speaking centers. Strong geographic variation was reported for medication for asthma. Asthma seems to be undertreated in several countries. Environmental exposures and in particular indoor factors, and exposures at the workplace are playing a major role for asthma in adulthood. Furthermore, protective effects on atopy were found for exposures to pets (dogs) and a large number of siblings in early childhood. In conclusion, the ECRHS has shown that the prevalence of asthma varies widely. The fact that the geographical pattern is consistent with the distribution of atopy and bronchial responsiveness supports the conclusion that the geographical variations in the prevalence of asthma are true and likely due to environmental factors.     

ARIA (Allergic Rhinitis and its Impact on Asthma) achievements in 10 years and future needs

Allergic rhinitis and asthma represent global health problems for all age groups. Asthma and rhinitis frequently co-exist in the same subjects. Allergic Rhinitis and its Impact on Asthma (ARIA) was initiated during a World Health Organization (WHO) workshop in 1999 and was published in 2001. ARIA has reclassified allergic rhinitis as mild/moderate-severe and intermittent/persistent. This classification schema closely reflects the impact of allergic rhinitis on patients. In its 2010 Revision, ARIA developed clinical practice guidelines for the management of allergic rhinitis and asthma co-morbidities based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation). ARIA has been disseminated and implemented in over 50 countries of the world. In Turkey, it is important to make a record of ARIA achievements and to identify the still unmet clinical, research and implementation needs in order to strengthen the 2011 EU Priority on allergy and asthma in children.     

Consensus statement by the French Society of Endocrinology (SFE) and French Society of Pediatric Endocrinology & Diabetology (SFEDP) on diagnosis of Cushing's syndrome

Cushing's syndrome is defined by prolonged exposure to glucocorticoids, leading to excess morbidity and mortality. Diagnosis of this rare pathology is difficult due to the low specificity of the clinical signs, the variable severity of the clinical presentation, and the difficulties of interpretation associated with the diagnostic methods. The present consensus paper by 38 experts of the French Society of Endocrinology and the French Society of Pediatric Endocrinology and Diabetology aimed firstly to detail the circumstances suggesting diagnosis and the biologic diagnosis tools and their interpretation for positive diagnosis and for etiologic diagnosis according to ACTH-independent and -dependent mechanisms. Secondly, situations making diagnosis complex (pregnancy, intense hypercortisolism, fluctuating Cushing's syndrome, pediatric forms and genetically determined forms) were detailed. Lastly, methods of surveillance and diagnosis of recurrence were dealt with in the final section.     

The prevalence of asthma, allergic rhinitis, and atopy in Antalya, Turkey.

Bronchial asthma is a common chronic inflammatory disorder of the airways that causes serious morbidity and mortality. The prevalence of the disorder has been increasing, especially in developed countries. The population-based asthma prevalence studies provide data from Ankara, Istanbul, Gaziantep, Trabzon, Izmnir, and Kayseri in our country and asthma prevalence ranges between 1.4 and 3%. However, the prevalence of adult asthma in our city was not known. We aimed to determine the prevalence of asthma, allergic rhinitis, and atopy in the adult population of Antalya and compare the data with other countries and other regions of our country. The European Commission Respiratory Health Survey, the first study to assess the geographical variation in asthma and allergic diseases, provided comparable data from 22 countries and 140,000 individuals. Therefore, the European Commission Respiratory Health Survey protocol was preferred in our study. The first stage consisted of 1000 subjects; of these 1000 subjects, 200 subjects were randomly selected for the second stage. The response rates were 99.5 and 55.4% for stages I and II, respectively. The current prevalence of asthma, allergic rhinitis, and atopy in Antalya was 9.4, 27.7, and 31.1%, respectively. The most prevalent type of sensitization was mite allergy detected in 31 (20.9%) subjects. Sensitization to more than one allergen was frequent in subjects with asthma and allergic rhinitis. Bronchial asthma, allergic rhinitis, and atopy are frequent in our city and when compared with previous studies performed in Turkey, the highest results were in Antalya.     

Prevalence and comorbidity of allergic eczema, rhinitis, and asthma in a city in western Turkey.

BACKGROUND: Allergic diseases co-occur in many patients. There is no published population-based epidemiologic study about allergic diseases in Turkey. OBJECTIVE: The aim of this population-based study was to investigate the prevalence of allergic eczema, allergic rhinitis, and asthma and their co-occurence in Manisa. METHODS: The sample size was calculated using an estimated prevalence of ever wheezing for the analyzed age group. Interviews were conducted with 725 children. The survey instrument consisted of a set of sociodemographic questions plus the questionnaire of the International Study of Asthma and Allergies in Childhood. RESULTS: The mean (SD) age of the children studied was 8.94 (5.16) years. The prevalence of ever having allergic eczema was 4.7% whereas that of current allergic eczema was 3.2%. Current allergic rhinitis and allergic conjunctivitis were present in 14.5% and 13%, respectively. Asthma was reported in 14.7% of the children older than 3 years of age while the prevalence of physician-diagnosed asthma was 7.9%. The burden of allergy was 27.1%. The prevalence of concomitant eczema and rhinitis was 1.9%. Among children aged between 3 and 17 years, 1.5% and 4.7% had asthma along with eczema and rhinitis respectively. Asthma was significantly more common in children with rhinitis (31.5% vs 11.8%; P < .01; odds ratio [OR], 3.45). Asthma was diagnosed in 28.1% of children with eczema and 14% of children without eczema (P = .03; OR, 2.41). CONCLUSIONS: Atopic diseases seem to significantly increase the risk of developing another atopic disease with ORs that range from 2.4 to 3.4.     

Nasobronchial allergy or allergic rhinobronchitis; the unified concept: a review with a special reference to India

The close and constant association of allergic rhinitis (AR) and asthma, both in children and adults, is hardly mentioned in medical textbooks. Proper treatment is delayed, as these patients are often seen in rotation by chest physicians, allergy experts, otolaryngologists, general physicians and paediatricians. Even then treatment is directed mainly towards asthma with little attention being paid to associated rhinitis, often lying unrecognised in adults. The clinical pattern of asthma in children and adults differs in our country. Unless AR is treated simultaneously with asthma, recurrent AR will result likely in suboptimal control of asthma. Proof and arguement is brougnt forward to recognise the unified concept of nasobronchial allergy or rhinobronchitis for proper management.     

Prevalence and severity of asthma in adolescents in France. Cross-sectional and retrospective analyses of a large population-based sample.

SETTING: Asthma is the most common chronic respiratory disease among adolescents; however, very little is known about asthma in this age group. OBJECTIVE: To explore asthma in adolescence using cross-sectional and retrospective representative data. DESIGN: A population-based sample of adolescents was selected from 578 classes in 186 schools of eight metropolitan educational districts in France and invited to complete a self-administered questionnaire (National Adolescent Health Survey [NAHS]). RESULTS: Of 14,278 adolescents selected, 12,466 (87%) participated in the survey. Prevalence of 'ever asthma' was higher among boys, among those in the south and west, among those from French overseas departments, in active smokers, and in those with other allergies, including food allergy. It was lower in adolescents whose mother was a housewife. Puberty was not associated with 'ever asthma'; however, asthmatic boys without signs of puberty usually had more attacks than those with. Severe asthma was associated with early onset and female sex. Asthma medications and consultations did not depend on socio-economic status. Asthmatic adolescents were found to need more health care in terms of medication use, consultations and hospitalisations other than for asthma than other adolescents; this relationship was strongest among severe asthmatics.     

Exploration and management of adrenal incidentalomas.: French Society of Endocrinology Consensus

The French Society of Endocrinology convened a multidisciplinary panel of endocrinologists, radiologists, nuclear physicians and surgeons to address the appropriate evaluation and treatment of adrenal incidentalomas. The panel conducted a systematic review of medical literature on the following issues: epidemiology, natural history, radiological and scintigraphic evaluation, endocrine assessment, surgical management and appropriate follow-up. The following text reports the recommendations of experts on behalf of the French Society of Endocrinology. The authors emphasize the paucity of published scientific data that hampers evidence-based medicine recommendations. The crucial points of the French consensus are: the usefulness of CT-scanning evaluation of adrenal incidentalomas, the systematic screening for pheochromocytoma, the usefulness of the 1 mg overnight dexamethasone test to screen for latent hypercortisolism, the difficulty to interpret mild biological abnormalities of the HPA axis, the consensus to remove surgically most of tumours greater than 4 cm, the necessity to follow clinically glucorticoid tissular targets in the follow-up of non operated benign adrenocortical incidentalomas.     

Allergy in marathon runners and effect of Lactobacillus GG supplementation on allergic inflammatory markers

OBJECTIVE: We studied the prevalence of asthma and allergy in non-elite marathon runners and investigated the effects of probiotic supplementation on allergic inflammatory markers. METHODS: Asthma and allergies were surveyed by questionnaire, and blood eosinophils, serum eosinophil cationic protein (ECP), total IgE, and Phadiatop were measured in 141 Finnish marathon runners who took part in the Helsinki City Marathon. They were also randomized to receive either Lactobacillus GG (LGG) or placebo during the 3 months of the pollen season prior to the marathon. RESULTS: Lifetime prevalence of physician-diagnosed asthma was 4.3% (six out of 139 athletes), of allergic rhinitis 17.3% (24/139), of food allergy 5.0% (7/139), and of atopic eczema 4.3% (6/139). Prevalence of atopy was 31% (35/112), and 21% (24/112) of the athletes were sensitized to birch pollen. Asthma or allergy medication was used by 20% (28/139) of the athletes. During pollen season, serum ECP increased significantly in all athletes, and total IgE and Phadiatop in atopics. The marathon induced a significant eosinopenia but had no effect on serum ECP or total IgE. No differences in changes were seen between groups receiving LGG or placebo. CONCLUSION: Non-elite marathon runners have asthma and allergies similar to Finnish general population. LGG supplementation did not prevent the increase of allergic markers during the pollen season, or the eosinopenia induced by the marathon.     

The link between obesity and asthma: A Canadian perspective

Asthma is considered to be more prevalent in obese subjects, and a possible causal link between these two entities has been suggested. In the present study, various observations on this relationship were reviewed, and an analysis of data obtained from the 2000 to 2001 Canadian Community Health Survey on the prevalence of self-reported asthma, medication use and allergy, according to body weight, was reported. Asthma medication use and self-reported asthma were more prevalent in the obese population, particularly in women. Mean body mass index was higher in the asthmatic population compared with the nonasthmatic population. Self-reported nonfood-related allergies were higher in the more obese subjects in the general population, but the prevalence of allergy was not different in obese asthmatic subjects compared with nonobese asthmatic subjects. Smoking did not seem to influence the relationship between asthma and body mass index. Further research should investigate the mechanisms by which obesity may influence the prevalence of asthma or asthma-like symptoms.     

Primary asthma prevention: Is it possible?

Asthma, which typically begins in childhood and is the most common chronic disease of childhood, has reached epidemic proportions. Asthma is associated with gene-environment interactions, and there is consensus that a “window of opportunity” exists early in life when environmental factors may influence its development. This review considers biologic and sociologic factors in the development of allergy and asthma. Meta-analysis of studies demonstrates that monoallergen reduction does not impact asthma prevention. However, multifaceted allergen reduction studies have shown clinical benefit. We propose that allergic diseases, including asthma, represent a dysfunctional interaction with our environment and that the increasing prevalence of asthma and allergy herald increased population risk for the development of other inflammatory and autoimmune diseases. Better understanding of the complex factors for asthma and allergies may provide insight into many other chronic complex diseases.     

Paranasal computed tomography results in asthma patients: association between sinus sites and allergen types

Chronic rhinosinusitis (CRS) is a common comorbidity of asthma. The aim of this study was to investigate the relationships between the presence of rhinosinusitis, sinus site involvement, and total computed tomography (CT) sinus scores and the presence of allergy, allergen type, and severity of disease. Asthma patients (128 subjects), consisting of 57 allergic and 71 nonallergic patients, were included in the study. Presence of rhinosinusitis and sinus scores were evaluated by CT. CRS was determined in 45 (78.9%) allergic asthma patients and 44 (62.0%) nonallergic asthma patients (p<0.05). Ethmoid sinus involvement was higher among allergic asthma patients compared with nonallergic patients (68.4% versus 43.7%; p=0.005). House-dust mite allergy (71.4% versus 46.5%; p=0.008) and pollen allergy (73.5% versus 47.9%; p=0.01) showed positive correlations with ethmoid sinus involvement. No correlation was found between severity of disease and mean total CT sinus scores (p>0.05). The present study has shown the prevalence of chronic sinusitis to be higher in patients with allergic asthma, particularly in patients allergic to house-dust mites and pollens, with no correlation between severity of disease and presence of CRS. Investigating chronic sinusitis together with allergen sensitivity early in asthma diagnosis may contribute positively to patient treatment.     

The international study of asthma and allergies in childhood (ISAAC): phase three rationale and methods.

The International Study of Asthma and Allergies in Childhood (ISAAC) programme commenced in 1991 to study the aetiology of asthma, allergic rhinoconjunctivitis and atopic eczema in children in different populations using standardised methodology and facilitating international collaboration. ISAAC Phase One (1992-1996) found marked differences in the prevalence of symptoms of asthma and allergic disease throughout the world which have not been explained by the current understanding of these diseases. ISAAC Phase Two (1998-2004) uses intensive investigations to further examine the potential role of risk and protective factors that may contribute to the international difference observed in Phase One. Phase Three (2000-2003) essentially represents a repeat of Phase One, in which more detailed standardised data are obtained to enable the time trends of symptom prevalence to be determined as well as the development of a more comprehensive 'world map'. The ISAAC Phase Three rationale and methods are described in this paper. With over 280 centres in 106 countries, we anticipate that ISAAC Phase Three will comprehensively determine the prevalence of symptoms of asthma and allergic disease worldwide, explore recent time trends in the prevalence of these symptoms and cast new light on the aetiology of asthma and allergic disease.     

Factors related to under-diagnosis and under-treatment of childhood asthma in metropolitan France

Background

Under-diagnosis and under-treatment of childhood asthma were investigated in France using data collected during the 6 Cities Study, the French contribution to the International Study of Asthma and Allergies in Childhood.

Methods

7,781 schoolchildren aged between 9 and 10?years underwent a medical visit including skin prick tests to common allergens and exercise test for Exercise-Induced Asthma (EIA) and their parents filled in a standardized questionnaire on asthma, management, treatment and potential risk factors.

Results

903 children reported asthma (11.6%), 377 without a doctor??s diagnosis. Of the 526 participants with a diagnosis of asthma confirmed by a doctor (58.2%), 353 were treated and 76 were not treated during the year preceding the investigation despite their diagnosis. The information on the treatment was missing for the rest of individuals diagnosed with asthma (n = 97). Having a treatment was significantly associated with severe asthma and with the presence of other respiratory and allergic stigmata (atopic eczema, rhinitis, positive skin allergy tests, and EIA). In addition, having a treatment did not correspond to a good control of the disease. Similarly, children with asthma-like symptoms but without doctor-diagnosed asthma had asthma less well controlled than children with diagnosed asthma. They were also more exposed to passive smoking and traffic but had fewer pets. In contrast, diagnosed children reported more frequently a small weight at birth and a preterm birth.

Conclusions

In France, childhood asthma is still under-diagnosed and under-treated and environmental factors play a role in these phenomena.     

Secondary and tertiary prevention of allergic asthma in children

Asthma is a disease of the lung epithelial barrier, most often associated with allergy in children. Asthma and allergy are two distinct diseases, but the phenotypic expression of asthma depends on atopic status. A better definition of phenotypes of asthma would result in better targeting of prevention and treatment modalities. Secondary prevention aims to prevent the onset of asthma and the acquisition of new sensitizations in sensitized children. Studies concerning allergen avoidance are insufficient to reach a definitive conclusion and antihistamines have not been shown to be effective. The results for specific immunotherapy suggest a benefit to prevent transition from allergic rhinitis to asthma and the onset of new sensitizations. Tertiary prevention aims to reduce symptoms in children with an existing allergic asthma diagnosis. The avoidance of known respiratory allergens will only be effective in combination with management of the whole environment. Specific immunotherapy has a real place, in combination with background therapy. It should be used according to guidelines in appropriately treated patients.     

Trends in the prevalence of asthma and allergic rhinitis in Italy between 1991 and 2010

The prevalence of asthma increased worldwide until the 1990s, but since then there has been no clear temporal pattern. The present study aimed to assess time trends in the prevalence of current asthma, asthma-like symptoms and allergic rhinitis in Italian adults from 1990 to 2010. The same screening questionnaire was administered by mail or phone to random samples of the general population (age 20-44 yrs) in Italy, in the frame of three multicentre studies: the European Community Respiratory Health Survey (ECRHS) (1991-1993; n = 6,031); the Italian Study on Asthma in Young Adults (ISAYA) (1998-2000; n = 18,873); and the Gene Environment Interactions in Respiratory Diseases (GEIRD) study (2007-2010; n = 10,494). Time trends in prevalence were estimated using Poisson regression models in the centres that repeated the survey at different points in time. From 1991 to 2010, the median prevalence of current asthma, wheezing and allergic rhinitis increased from 4.1% to 6.6%, from 10.1% to 13.9% and from 16.8% to 25.8%, respectively. The prevalence of current asthma was stable during the 1990s and increased (relative risk 1.38, 95% CI 1.19-1.59) from 1998-2000 to 2007-2010, mainly in subjects who did not report allergic rhinitis. The prevalence of allergic rhinitis has increased continuously since 1991. The asthma epidemic is not over in Italy. During the past 20 yrs, asthma prevalence has increased by 38%, in parallel with a similar increase in asthma-like symptoms and allergic rhinitis.     

The clinical spectrum of ocular allergy

Ocular allergy is a very common pathology, and its incidence has increased in industrial countries in combination with an increase in atopy. Many different clinical features characterize the ocular allergy, which can be seasonal, perennial, or chronic. Therefore, ocular allergy must be considered part of the allergic syndrome; perennial or seasonal keratoconjunctivitis appear to be directly related to allergic rhinitis manifestations and, less frequently, to asthma and eczema. The principal field of reserch in ocular allergy concerns therapeutic applications and new concepts of physiopathologic mechanisms needed to understand the most optimal treatment that can be delivered.     

Prevalence of asthma and asthma-like symptoms in three French cities

Background. This study is part of the European Community Respiratory Health Survey (ECRHS), which uses a common methodology in different areas throughout the world. This paper describes the prevalences of reported asthma, asthma-like symptoms and nasal allergies, their relationships to age group and sex, and the relationships of asthma-like symptoms to current asthma, in the general population aged 20–44 years of three French urban areas.Methods. The study population of 2804 subjects in Grenoble, 3774 in Montpellier and 3152 in Paris (18th district), randomly selected from electoral rolls, answered a postal questionnaire (stage I of ECRHS). The response rates were 77.8%, 68.6% and 74.4%, respectively.Results. The prevalences were approximately 14% for wheezing, 16% for chest tightness and 4.5% for nocturnal shortness of breath in the three areas. Asthma attacks in the last 12 months were reported by 2.7% of subjects in Grenoble, 3.5% of subjects in Montpellier and 4.0% of subjects in Paris (P=0.02). For nasal allergies, the prevalences were 28.0%, 34.3% and 30.8%, respectively (P<0.001). Asthma was inversely correlated to age (higher prevalence in the youngest) but was not related to sex. Neither age distribution nor sex ratio explained the differences between areas. Among the asthma-like symptoms, wheezing and nocturnal shortness of breath correlated strongly with asthma, chest tightness correlated moderately and nocturnal coughing correlated poorly.Conclusion. The prevalences observed were higher than expected from previous comparable French studies in young adults. These results are consistent with the hypothesis of a recent increase of asthma and allergies.     

Asthma-related resource use and cost by GINA classification of severity in three European countries

BACKGROUND: This study assessed the relationship between asthma burden and asthma severity in France, Italy, and Spain. METHODS: Adult asthmatics, 18-55 years of age, completed a questionnaire while visiting a respiratory physician in 1998 and 1999. Asthma severity was categorized by physicians as intermittent, mild persistent, moderate persistent, or severe persistent according to Global Initiative for Asthma (GINA) guidelines. RESULTS: Totals of 282 patients in France, 500 in Italy, and 296 in Spain entered the study. There were few differences between the three countries in the asthma symptom burden. Most patients with persistent asthma had used inhaled corticosteroids in the previous 14 days. Unexpectedly, 35% (Italy) to 83% (Spain) of patients with intermittent asthma also had used inhaled corticosteroids. In Spain, visits to the emergency department were more frequent (OR 7.0, 95% CI 4.9-10.0 with Italy as reference) and the costs of emergency care in all asthma severity categories were up to 10 times higher than in Italy and France. The frequency of hospitalizations did not differ systematically between the three countries. CONCLUSIONS: Inadequate control of asthma symptoms among patients with severe persistent asthma could not be entirely explained by under-prescribing of asthma medications. The use of inhaled corticosteroids by patients with intermittent asthma might reflect misclassification of asthma severity, possibly due to difficulty in interpreting the GINA guidelines. The relatively high cost of emergency care in Spain does not appear to be related to greater asthma severity or poorer symptom control, but may be a feature of the Spanish health care system.     

Phase II of the International Study of Asthma and Allergies in Childhood (ISAAC II): rationale and methods.

International comparative studies, investigating whether disease incidence or prevalence rates differ between populations and, if so, which factors explain the observed differences, have made important contributions to the understanding of disease aetiology in many areas. In Phase I of the International Study of Asthma and Allergies in Childhood (ISAAC), the prevalence rates of symptoms of asthma, allergic rhinitis and atopic eczema in 13-14-yr-olds, assessed by standardised questionnaires, were found to differ >20-fold between the 155 study centres around the world. Phase II of ISAAC aims to identify determinants of these differences by studying informative populations. A detailed study protocol was developed for use in community-based random samples of children aged 9-11 yrs. The study modules include standardised questionnaires with detailed questions on the occurrence and severity of symptoms of asthma, allergic rhinitis and atopic eczema, their clinical management, and a broad range of previous and current exposure conditions. In addition, standardised protocols were applied for examination of flexural dermatitis, skin-prick testing, bronchial challenge with hypertonic saline, blood sampling for immunoglobulin E analyses and genotyping, and dust sampling for assessment of indoor exposures to allergens and endotoxin. To date, ISAAC II field work had been completed or started in 30 study centres in 22 countries. The majority of centres are in countries that participated in International Study of Asthma and Allergies in Childhood Phase I and reflect almost the full range of the observed variability in Phase I prevalence rates.