Onset of allergy and asthma symptoms in extra-European immigrants to Milan, Italy: possible role of environmental factors.

Miadonna A.

First Division of Internal Medicine, IRCCS Ospedale Maggiore Policlinico, Milan, Italy.

BACKGROUND: Allergy and asthma are typical disorders of the affluent societies. Migrants from developing to industrialized countries seem to be at increased risk of allergy and asthma development. OBJECTIVE: To evaluate time of onset, spectrum of sensitization and clinical features in a population of extra-European immigrants to Milan, Italy, complaining of allergy and asthma symptoms. METHODS: Data regarding 243 extra-European immigrants checked at an allergy clinic from 1994 to 2000 were collected retrospectively. The demographic data were compared with those of the extra-European immigrants living in Milan at the end of 1999. RESULTS: The patients were complaining of asthma (63.7%), rhinoconjunctivitis (56.7%), rhinitis alone (21%) or urticaria (3%). One hundred and eighty-seven out of 222 patients (84.3%) declared they were healthy before migrating and allergy/asthma symptoms started to appear after their arrival in Italy, namely after an average period of 4 years and 7 months. The proportion of male patients was lower than the proportion of men in the extra-European immigrant population (48% vs. 55%), suggesting that in adult immigrants allergy and asthma are more common in women than in men. Furthermore, there was an over-representation of Central-South Americans attending the clinic, which seemed to be due to a genetic predisposition to allergy/asthma development. When data were analysed for single countries, a trend towards an increased risk of allergy and asthma was found in immigrants from all Central-South American countries. A skin test positivity for at least one inhalant allergen was found in 196 out of 232 patients (81%), and the spectrum of allergic sensitization was similar to that of the Italian population living in the North of Italy. CONCLUSION: Most extra-European immigrants declared that they were healthy at home and that allergy and asthma symptoms had appeared after immigration to Milan; lifestyle and environmental factors in a western industrialized city seem indeed to facilitate allergy/asthma onset in immigrants from developing countries. Allergy/asthma risk seems to be different in different ethnic groups.

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SMS Medical Outcomes Research Project Asthma Outcomes Study. Provider education the next step.

Adult Asthma Toolkit Subcommittee.

Center for Medical Practice Research and Education, State Medical Society of Wisconsin (SMS), USA.

Since the initial meeting of the Asthma Study Group in the summer of 1996, the group worked with MORP staff to develop an outcomes instrument, define a study population, survey more than 800 adults with the diagnosis of asthma, and report the survey results back to the providers involved with those patients. After reviewing the survey results, the group developed an Asthma Toolkit aimed at providing reference materials for physicians and their staff and also useable materials for their patients with asthma. The Asthma Toolkit was produced through the efforts of the study group, the SMS MORP staff and the SMS Marketing and Communications Department. We developed an education program to disseminate the toolkit and improve the care of the patient with asthma. Initial reaction to this educational program has been enthusiastic, and evaluation of the Asthma Toolkit's usefulness is underway.

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Is childhood asthma underdiagnosed and undertreated?

Oviawe O.

Department of Paediatrics and Child Health, College of Medicine of the University of Lagos, P.M.B 12003, Idi-Araba, Lagos.

Underdiagnosis of asthma may lead to inappropriate management including undertreatment, and consequently to high morbidity and mortality. This study aimed at determining the rates of diagnosis and treatment of childhood asthma among medical practitioners. Relevant information on 45 asthmatic children was collected using pre-tested questionnaires. There were 30 (66.7%) males and 15 (33.3%) females (M:F, 2:1). Mean age, average ages for onset of symptoms and diagnosis of asthma were 9.4 years, 1.8 years and 6.6 years respectively. An average of 4 previous medical consultations were undertaken for asthma symptoms, but only 11 (24.4%) cases were labeled as asthma. Alternative diagnostic labels including allergy, bronchitis (wheezy), pneumonia (chest infection), and tuberculosis, were used in 29 (64.4%). Five (11.1%) cases were unlabelled. Alternative labeling for asthma was associated with frequent usage of non-bronchodilator medications including antihistamines, antibiotics, antituberculous drugs, cough mixtures, and herbal concoctions. Only 15 (33.3%) cases received bronchodilators, rarely prescribed regularly in the absence of asthma label. This study reveals low diagnosis and treatment rates for asthma, emphasising the need to audit the management of childhood asthma among medical practitioners, with the view of providing information.

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[Nonspecific bronchial hyperreactivity in asthma patients with or without allergic rhinitis]

[Article in Lithuanian]

Bajoriuniene I.

Laboratory of Pulmonology, Institute for Biomedical Research, Kaunas University of Medicine, Lithuania. kestutis.malakauskas kmu.lt

Bronchial hyperresponsiveness is the main pathophysiological feature of asthma. Eosinophilic inflammation of airway is one of main factors influencing bronchial hyperresponsiveness. The aim of the study was to evaluate bronchial responsiveness to methacholine and exercise of asthma patients with or without allergic rhinitis and to estimate relations between eosinophil count in nasal secretion and non-specific bronchial hyperresponsiveness. Ninety eight patients with mild or moderate asthma were examined. Seventy eight patients had mild allergic rhinitis. Patients were divided in two groups: asthma with rhinitis group (n=78) and asthma group (n=20). Bronchial responsiveness was tested with methacholine and exercise challenges. Allergic status was determined by skin prick tests, mean wheal size and eosinophil count in the blood and nasal secretion. Atopy was more frequent (p=0.001) and mean wheal size larger (p=0.002) in asthma with rhinitis group. No difference estimated on blood eosinophil count (p=0.125) between both groups. Nasal eosinophil count was higher in asthma with rhinitis group comparing with asthma group (p=0.001). Methacholine provocative dose (PD(20)) was lower and the slope of the dose-response curve higher in asthma with rhinitis group, but not statistically significantly: PD(20) 173.0+/-27.0 microg and 212.1+/-52.9 microg, accordingly, p=0.179; the slope of the dose-response curve - 23.6+/-1.6 and 20.7+/-2.5, p=0.219. Exercise-induce bronchoconstriction developed equally: to 46% patients (n=36) from asthma with rhinitis group and 45% patients (n=9) asthma group. No significant differences were found between maximal fall of FEV(1)after exercise (DeltaFEV (1)): 24.2+/-2.3% and 25.9+/-4.0%, accordingly, p=0,744; area under the curve (AUC(0-30)): 451.6 +/- 48.9 % x sec. and 484.0+/-111.0% x sec., p=0.777. No statistical significant correlations were evaluated between nasal eosinophilia and PD(20), the slope of the dose-response curve, DeltaFEV(1) and AUC(0-30). CONCLUSIONS: No significant differences were estimated on bronchial responsiveness to methacholine and exercise between asthma patients with or without allergic rhinitis. Eosinophil count in nasal secretion did not correlate with non-specific bronchial hyperresponsiveness.

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[The immunological parameters and risk factors for pollen-induced allergic rhinitis and asthma]

[Article in Lithuanian]

Sakalauskas R.

Institute for Biomedical Research, Kaunas University of Medicine, Lithuania. juratest hotmail.com

Naturally occurring exposure to pollen allergens causes symptoms of allergic rhinitis, conjunctivitis and asthma in susceptible individuals. It is, however, unknown why some subjects develop only an allergic rhinitis while others develop asthma as well. The aim of this study was to investigate the difference of immunological parameters in patients with pollen-induced seasonal allergic rhinitis (SAR) and asthma and to determine the risk factors for pollinosis with asthma. We evaluated the demographic and clinical characteristics of the patients, sensitisation pattern to tree-, grass- and weed-pollen and perennial inhalant allergens according to skin prick tests, allergic inflammation parameters (blood and nasal eosinophil count, serum IgE, eosinophil cationic protein levels) in and out of the pollinosis season. Logistic regression analysis was used to rate the effect of covariates on risk for pollinosis and asthma. One hundred and one patients (52 men and 49 women) aged 16-63 years (median 24 yrs.) with pollinosis symptoms were investigated. All patients suffered from moderate-severe seasonal allergic rhinitis, 96% from concomitant allergic conjunctivitis, 23.8% had seasonal asthma. The significant clinical and demographic risk factors for pollinosis with asthma were smoking (OR=15.4, p=0.003) and pollinosis season lasting more than 14 weeks (OR=5.6, p=0.02). The patients with seasonal allergic rhinitis alone were significantly more frequently sensitized to orchard grass (p=0.005), ragweed (p=0.02), lamb's quarter (p=0.05) allergens. During the season the blood eosinophil count raised in all patients (p<0.01). It was shown statistically that there were no differences between groups in blood and nasal eosinophil count, serum eosinophil cationic protein level. The patients with seasonal allergic rhinitis and asthma had higher levels of serum IgE during the season (p=0.05) and out of it (p=0.01). More than two times elevated serum IgE in acute and symptom-free period of pollinosis was considered as a significant risk factor for pollinosis with asthma (OR=3.5, p=0.04 and OR=3.4, p=0.03). CONCLUSIONS: Pollinosis presented with seasonal asthma in 23.8% of cases. Our data indicate that patients with seasonal allergic rhinitis and asthma differ from the patients with seasonal allergic rhinitis alone according to higher serum IgE levels. Prolonged pollinosis season, smoking and high IgE levels increase the risk for seasonal asthma in pollen-induced allergic rhinitis subjects.

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Key clinical activities for quality asthma care. Recommendations of the National Asthma Education and Prevention Program.

National Asthma Education and Prevention Program.

Division of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC, Atlanta, Georgia, USA.

In 1997, the National Asthma Education and Prevention Program (NAEPP), coordinated by the National Heart, Lung, and Blood Institute, published the second Expert Panel Report (EPR-2): Guidelines for the Diagnosis and Management of Asthma (National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the diagnosis and management of asthma. Bethesda MD: US Department of Health and Human Services, National Institutes of Health, 1997; publication no. 97-4051. Available at http://www.nhlbi.nih.gov/guidelines/ asthma/asthgdln.pdf). Subsequently, the NAEPP Expert Panel identified key questions regarding asthma management that were submitted to an evidence practice center of the Agency for Healthcare Research and Quality to conduct a systematic review of the evidence. The resulting evidence report was used by the Expert Panel to update recommendations for clinical practice on selected topics. These recommendations (EPR-Update 2002) were published in 2002. (National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Guidelines for the diagnosis and management of asthma--update on selected topics 2002. J Allergy Clin Immunol 2002;110[November 2002, part 2]. Available at http://www.nhlbi.nih.gov/guidelines/asthma/index.htm). To improve the implementation of these guidelines, a working group of the Professional Education Subcommittee of the NAEPP extracted key clinical activities that should be considered as essential for quality asthma care in accordance with the EPR-2 guidelines and the EPR-Update 2002. The purpose was to develop a report that would help purchasers and planners of health care define the activities that are important to quality asthma care, particularly in reducing symptoms and preventing exacerbations, and subsequently reducing the overall national burden of illness and death from asthma. This report is intended to help employer health benefits managers and other health-care planners make decisions regarding delivery of health care for persons with asthma. Although this report is based on information directed to clinicians; it is not intended to substitute for recommended clinical practices for caring for persons with asthma, nor is it intended to replace the clinical decision-making required to meet individual patient needs. Readers are referred to the EPR-2 for the full asthma guidelines regarding diagnosis and management of asthma or to the abstracted Practical Guide (National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Practical guide for the diagnosis and management of asthma. Bethesda MD: US Department of Health and Human Services, National Institutes of Health, 1997; publication no. 97-4053. Available at http://www.nhlbi.nih.gov/health/prof/lung/asthma/practgde.htm) and to the EPR-Update 2002. The 1997 EPR-2 guidelines and EPR-Update 2002 were derived from a consensus of leading asthma researchers from academic, clinical, federal and voluntary institutions and based on scientific evidence supported by the literature. The 10 key activities highlighted here correspond to the four recommended-as-essential components of asthma management: assessment and monitoring, control of factors contributing to asthma severity, pharmacotherapy and education for a partnership in care. The key clinical activities are not intended for acute or hospital management of patients with asthma but rather for the preventive aspects of managing asthma long term. This report was developed as a collaborative activity between CDC and the NAEPP.

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Allergen sensitivity and asthma severity at an inner city asthma center.

Joks R.

SUNY Downstate, Asthma Center of Excellence, Brooklyn, New York 11203-2098, USA.

The objective of this study was to examine the relationship of allergen sensitivity to asthma symptoms among inner-city asthmatics seen at our Brooklyn, NY, asthma center. We hypothesized that asthma severity would increase for adults and children with increased cockroach and dust mite allergen sensitivity. Data were gathered from retrospective chart review for all patients who were treated at the center with a diagnosis of asthma and had undergone skin-prick testing (SPT) for allergen sensitivity during 1998 (pediatric, n = 79; adult, n = 29). Asthma severity (determined by National Heart, Lung and Blood Institute [NHLBI] asthma severity class) was examined in relation to allergen sensitivity. Allergen sensitivity was measured by percent positive to skin-prick testing as well as by relative mean diameter of skin prick test wheals. For adults, mite sensitivity prevalence was 61% and cockroach sensitivity prevalence was 41%. For children, mite sensitivity prevalence was 49%; cockroach sensitivity prevalence was 42%. For adults, asthma severity correlated significantly with sensitivity to Cladosporium, tree, and grass as measured by percent positive skin tests and by increasing mean diameter of skin test wheals. There was a significant correlation with severity for adult dust mite sensitivity only as measured by increasing mean wheal diameter. Ragweed sensitivity showed a significant correlation with severity only as measured by percent positive skin tests. There was a significant positive association for adults between increasing asthma severity and total number of allergen sensitivities per subject. There was no significant correlation for children between asthma severity and total number of allergen sensitivities per subject. Among children, no specific allergen sensitization showed a significant positive association with asthma severity. By both measures of allergen sensitization, there was a significant negative association for children between Cladosporium and asthma severity. Among our inner-city asthmatic population significant correlation between mite sensitivity and asthma severity was found only in adults. No significant association was seen with cockroach. However, outdoor allergen sensitivity (Cladosporidium, tree, ragweed, and grass) significantly correlated with asthma for adults in this inner city population.

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Pseudoseizures and asthma.

Toone BK.

National Neuropsychiatry Unit, Maudsley Hospital, London SE5, UK.

BACKGROUND: Sexual abuse and head injury are important risk factors of pseudoseizures, reported in about a third of patients. Clinical experience suggests that asthma is another possible risk factor. OBJECTIVES: To determine the relative prevalence of asthma in patients with pseudoseizures. METHODS: A retrospective record review was undertaken of reported asthma in 102 patients with pseudoseizures and 70 psychotic controls. The pseudoseizure patients were subgrouped according to method of diagnosis: 47 in whom epilepsy was excluded by capturing a typical attack on video-electroencephalographic monitoring (VEEM), and 55 not diagnostically confirmed with VEEM. RESULTS: Asthma was reported in 26.5% of pseudoseizure patients, compared with 8.6% of the psychotic controls (chi(2) = 8.6; p = 0.003). Asthma was reported at similar rates in the VEEM confirmed (29.8%) and non-VEEM confirmed (23.6%) pseudoseizure subgroups. The significant excess of reported asthma held for both the VEEM confirmed subjects (Pearson's chi(2) = 5.4, p = 0.02) and non-VEEM confirmed subjects (Pearson's chi(2) = 8.9, p = 0.003). CONCLUSIONS: There is an association between pseudoseizures and reported asthma. Various models are proposed whereby somatisation, anxiety hyperventilation, and dissociative elaboration may account for the observed association. Both asthma and anxiety hyperventilation may be important risk factors for the development of pseudoseizures. The reported asthma may itself be psychogenic in origin in a proportion of patients. Confirmatory prospective studies are indicated.

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