National Asthma Campaign Research Articles

Age at onset of different pubertal signs in boys and girls and differential DNA methylation at age 10 and 18years: an epigenome-wide follow-up study.

STUDY QUESTIONIs the age of onset of pubertal markers related to subsequent changes in DNA methylation (DNAm)?SUMMARY ANSWERWe identified 273 cytosine-phosphate-guanine (CpG) dinucleotides in girls and 67 CpGs in boys that were related to puberty and that were replicable in two other investigations.WHAT IS KNOWN ALREADYPreviously, 457 CpGs (not gender-specific) and 347 (in girls) and 50 (in boys), respectively, were found to be associated with puberty, according to investigations of studies from Denmark (20 girls and 31 boys) and North America (30 girls and 25 boys).STUDY DESIGN, SIZE, DURATIONThe study was based on a birth cohort of 1456 participants born in 1989/90, with follow-up at age 10 and 18 years.PARTICIPANTS/MATERIALS, SETTING, METHODSThe follow-up included 470 participants with information on DNAm and age of pubertal onset (244 girls and 226 boys). Age of pubertal onset was ascertained retrospectively at age 18 years. Using the Pubertal Development Scale, both genders were asked about ages of onset of growth spurt, body hair growth and skin changes. Ages at voice deepening and growth of facial hair were inquired from boys; ages at breast development and menarche from girls. Blood samples were collected at 10 and 18 years of age. DNA was extracted using a standard salting out procedure. The methylation level for each CpG site was assessed using one of two different platforms. DNAm was measured by a ratio of intensities denoted as β values for each CpG site. After quality control, 349 455 CpG sites were available for analysis. M values were calculated (log2(β/(1−β)) to approximate a normal distribution, and their levels were adjusted for blood cell proportions. Linear mixed models were applied to test the association between age of pubertal markers and repeated measurement of DNAm at 10 and 18 years.MAIN RESULTS AND THE ROLE OF CHANCEIn girls, a total of 63 019 CpGs statistically significantly changed after occurrence of any of the five pubertal events and 13 487 were changed subsequent to all five events: the respective number is boys were 3072 and 301. To further exclude false-positive findings, we investigated which CpGs were replicable in prior studies from Denmark or North America, resulting in 273 replicable CpG in girls and 67 CpGs in boys (236 and 68 genes, respectively). Most identified genes are known to be related to biological processes of puberty; however, genetic polymorphisms of only four of these genes were previously linked to pubertal markers in humans.LIMITATIONS, REASONS FOR CAUTIONThe relative age of pubertal onset to the age of DNAm measurements does not allow causal inference, since DNAm at an earlier age may have affected the pubertal age or pubertal age may have altered later DNAm. This investigation concentrates on autosomes. CpGs on X and Y chromosomes are not included in the current study.WIDER IMPLICATIONS OF THE FINDINGSAssessment of biological processes involved in pubertal transitions should include epigenetic information. Differential DNAm related to puberty needs to be investigated to determine whether it can act as an early marker for adult diseases known to be associated with puberty.STUDY FUNDING/COMPETING INTEREST(S)This work was supported by NIH grants R03HD092776 (Epigenetic characterization of pubertal transitions) and R01AI121226. The 10-year follow-up of this study was funded by National Asthma Campaign, UK (Grant No 364), and the 18-year follow-up by a grant from the National Heart and Blood Institute (R01 HL082925). The authors have no conflicts to report.

The Association between Obesity and Severityof Asthma in Children

Introduction: Asthma is the most common chronic airway disease in children, which is caused by genetic and environmental factors such as obesity. The aim of this study was to evaluate the relationship between obesity and asthma severity in children. Methods: This cross-sectional descriptive study included 200 asthmatic children aged 6 to 12 years in Yazd Shohadaye Kargar hospital in 2015 - 2016. The participants' demographic data were recorded. According to the Australian National Asthma Campaign, they were categorized into mild, moderate, and severe groups considering their severity of asthma. In order to compare the studied variables t, chi-square, and Mann-Whitney tests were used by SPSS 18. Results: The results showed that 11 (27.5%) obese children had severe asthma, but only 7 children (4.4%) with normal BMI had severe asthma (P <0.001). It was also found that the mean BMI in children with severe asthma was 21.68, in children with moderate asthma was 19.73, and in children with mild asthma was 18.27 (P <0.001). Other variables including age, birth weight, maternal age, socioeconomic status, and educational level did not have any significant effect on the severity of asthma (P> 0.05). Conclusion: Our study showed that the prevalence of severe asthma was high in obese children and this relationship was stronger in boys. Therefore, obese children have a higher risk for severe asthma. To reduce obesity in children, treatments such as regimen are required.

Asthma friendly schools: The importance of school policy for children with asthma

Asthma friendly schools: The importance of school policy for children with asthma

Asthma management: latest guidelines

Asthma guidelines were available from the early 1990s but were consensus opinion rather than evidence based, as was the long-awaited revised 1997 asthma guideline (British Thoracic Society, National Asthma Campaign, and Royal College of Physicians of London et al 1997). A further five years lapsed before updated guidelines were introduced, but this time they were based on evidence that was classified according to the academic rigour of the research. It is now difficult to think of asthma management in the UK without the benefit of these guidelines, especially in primary care. Although difficult to prove conclusively, it is possible that this evidence-based approach to asthma management in primary care is one of the factors that have contributed to a decline in acute presentations of asthma (Fleming et al 2000).

Results of a national asthma campaign survey of primary care in Scotland

To identify within primary care in Scotland how far procedures for asthma review and patient education match guideline recommendations. Telephone survey of a one in four stratified random sample of all 1058 general practices in Scotland. Practice nurses, general practitioners. Number of practices matching guideline recommendations for asthma review, targeting of care, use of structured asthma records, provision of management plans, education, and regular audit. Of 276 general practices contacted 91% (251) completed the questionnaire; 93% (228) ran an asthma review service; 74% (166) employed a specially trained asthma nurse; 39% (106) had a policy for providing action plans; 63% (155) had carried out an asthma audit in the previous 3 years; 76% (218) used a structured tool in consultations, 46% with use of computer technology, 34% used only a manual stamp. Sixty-six per cent (173) had searched for patients overusing beta2 agonists; 32% (79) had searched for patients on medication treatment step 3 and above. Single- or two-partner practices were less likely to follow guideline recommendations but neither rurality nor deprivation was related to guideline compliance. Three-quarters of Scottish general practices have trained asthma nurses and offer patients asthma review, but only a minority have proactive care procedures for targeting patients or a policy for providing patients with action plans. Practice systems are underused for identifying 'at-risk' patients. There is a need for proactive procedures and provision of self-management materials to patients. Access to trained asthma nurses needs to be improved.

Asthma patients live in constant fear

More than half a million people with asthma in the UK are living in constant fear that their next attack will be the one that kills them. That is the startling claim of a new report by the charity Asthma UK (formerly known as the National Asthma Campaign).

How well do doctors know their patients with severe asthma?

Rates of asthma mortality have fallen in Australia since the commencement of the National Asthma Campaign and promotion of the Australian asthma management plan. New strategies are now needed to further reduce mortality. To examine agreement about key features between asthma patients and their general practitioners (GPs). We interviewed: (i) the next of kin of 56 asthma deaths, (ii) 91 asthma patients presenting to emergency departments with acute severe asthma and (iii) 147 of their GPs. Agreement was substantial for usage of oral symptomatic medication, but poor for inhaled symptomatic and preventive medications. There was moderate agreement regarding hospital admissions within the last 12 months among the cases, but little about other markers of severity. There was moderate agreement where the presenting or fatal attack was triggered by an upper respiratory-tract infection or aspirin. The next of kin and GPs agreed about family problems, but not about other psychosocial issues. They also agreed about which cases had been given action plans or verbal instructions, but few other aspects of asthma management. There was also moderate agreement regarding the use of peak flow meters by the controls. Doctors often have relatively poor insights into self-management practices, social background or trigger factors, even in high-risk patients. This should be considered when planning future campaigns to improve asthma management and further reduce mortality.

Development of a Rural Asthma Management Model, RAMM

The prevalence of asthma in Australia is increasing and places a significant cost burden on the community as well as reducing individuals' quality of life. In the late 1990s, asthma was the sixth National Health Priority in Australia and the prevalence of asthma in the Loddon Mallee region (LMR) of Victoria was approximately 1% higher than the State average. Four LMR local government areas had close to double the State average hospital admission ratios for asthma. The aim of this project was to develop a Regional Asthma Management Model (RAMM) and strategies for its implementation throughout the LMR, as a tool to implement a major health priority of both the Victorian State and Australian Commonwealth governments: to improve health outcomes for people with asthma. A literature review was undertaken to identify best practice in asthma management for use as the basis of questions in workbooks designed to profile and compare current asthma management practice in the LMR. The workbooks were sent to all acute hospitals, community health centres and asthma educators in the LMR. The completed workbooks were returned and respondents elaborated on the workbook data at one of five subregional workshops. A survey was also undertaken to identify the range of asthma management strategies currently used by regional general practitioners (GPs) and to invite their views on ways to improve asthma management in the region. To gain consumer input into the RAMM a semi-structured group interview was held in an urban area and individual interviews were held in two rural areas in the region. A multidisciplinary reference group provided guidance to the project and a documentation design team was convened. Of the 19 workbooks sent to individual acute hospitals, 15 (78.9%) were completed and returned; 13 of 14 workbooks (92.8%) sent to individual community health centres were completed and returned. Fourteen of 15 asthma educators identified in the LMR were employed in the acute hospitals and community health centres that returned the workbooks; one asthma educator worked privately. Of the 215 GP surveys distributed, 38 surveys (17.6%) were returned. The majority of this small sample of GPs supported developing a uniform regional approach to asthma management based on NAC guidelines. Consumers interviewed suggested treating doctors, and/or EDs provide patients and carers with written instructions regarding acute asthma attacks and advice on management strategies for the ensuing 24-48 hours. A regional profile of asthma management practice was produced and compared with identified best practice. Gaps in practice and services were identified and responsive recommendations formulated. The National Asthma Campaign (NAC) guidelines were used as the basis for RAMM documentation, a package which consisted of a Regional Asthma Clinical Pathway and Emergency Department (ED) Package. The RAMM developed during the project provides documentation to assist best-practice asthma management by regional EDs and acute hospitals. The methodology and outcomes of the RAMM reflect the geography of the region, with multiple service providers from different locations managing a person with asthma across the primary, secondary and tertiary continuum. The RAMM methodology has the potential to be applied to other diseases and to other rural environments. Although the RAMM was designed for rural areas it could be easily adapted to suit the metropolitan environment. Implementation and evaluation of RAMM documentation is in progress.

General practitioners with a special interest in respiratory medicine.

This GPwSI framework is one of a number, which the Department of Health has commissioned the Royal College of General Practitioners (RCGP) to write. The RCGP has written the frameworks in conjunction with the General Practice Airways Group, General Practitioners, Consultants, PCT managers, patients, a range of organisations with an interest in respiratory medicine and the document has been amended to take their views into account. (National Asthma Campaign, National Respiratory Training Centre, Respiratory Education and Training Centre, British Thoracic Society, RCN forum for respiratory nurses, and The Department of Health and the Practitioners with Special Interests Team in the NHS Modernisation Agency. The frameworks aim to draw on good practice and experience nationally and are intended to be advisory for the development of local services

Assessment of key influences on asthma inhaler device selection in trained asthma practice nurses

The impact of asthma is felt throughout the UK with an average primary care organisation treating 45,000 people for asthma with 439 emergency hospital admissions and eight deaths due to asthma each year (National Asthma Campaign 2001). Optimal asthma management is reliant on individualised patient focused selection of appropriate treatment via a suitable inhaler device. To identify the most important influences on asthma inhaler device selection in a group of asthma trained nurses. Interviews and a focus group were conducted in order to gain information that could be used to develop a questionnaire on which to base a pilot study. Interviews, focus group and pilot study were all held in a semi-rural area of England. Subjects: 3 NRTC asthma nurse experts, eight local asthma trained practice nurses and a non random sample of 18 asthma trained nurses. Practice nurse's identified influences such as patient age, cost to the practice and patient preference as being the most important influences with experts also highlighting the importance of evidence from research and adherence to current national asthma guidelines. The subsequent pilot study showed that ease of use and patient's manual dexterity had the greatest influence on a nurse's choice of device, with adherence to national asthma guidelines and training in asthma management in third and fourth places. Inhaler devices need to be easy to use by the majority of patients to ensure optimal asthma management, while national asthma guidelines also play a prominent role in device selection. Asthma education should include this information in order to promote optimal symptom control.

The adaptation of written self-management plans for children with asthma.

Self-management plans are an important element of asthma care. Although asthma is common in children, there is limited guidance for adaptation of self-management plans for children. . A study was conducted in order to develop a set of criteria for adaptation of asthma self-management plans for school aged children; and to use these criteria to review self-management plans used in United Kingdom (UK) centres. Self-management plans were obtained by telephone survey (response rate: 81%) of 47 selected UK paediatric, respiratory and community centres during the period between March and October 2001. The content of self-management plans was analysed according to criteria developed from a review of the literature, including objectives, opportunities for individualization, and the implied roles of parent and child in asthma management. Agreement was achieved between the authors and a third independent rater. The majority of centres (31 of 47) used or planned to use adapted self-management plans while the remainder used the standard National Asthma Campaign self-management plan. There were wide variations in self-management plans, including variation in the person to whom plans were addressed, criteria for treatment and the objectives stated for self-management. Few opportunities were provided for individualization of self-management. The study was limited to the documents used in self-management in selected centres. The results suggest that many practitioners believe that self-management education requires adaptation for children. There is little consistency in the adaptation of self-management plans for children. Principles for devising adapted self-management plans are proposed.

What are the priorities in basic asthma research? A United Kingdom perspective

The National Asthma Campaign (in the United Kingdom) has recently completed a strategic review of priorities for basic asthma research over the next 5 to 10 years. Leading asthma experts and representatives of the main funding agencies were involved in a nationwide consultation. Discussions were carried out in 7 thematic areas: Genetics of asthma, early-life events, environmental influences, immunology and immunotherapy, inflammation and anti-inflammation, airway remodeling, and the interface between academia and industry. Discussions were not restricted by considerations of financial affordability but were driven by vision and science. The consultation highlighted a number of generic issues pertaining to the organization of basic asthma research. Phenotypes of asthma require more robust characterization, particularly for genetic studies. Emphasis on longitudinal studies should be encouraged, and more information can still be gained from existing well-characterized asthma cohorts, though this requires some coordination. Human research is particularly strong and should continue, and the use of human tissue is vital to our understanding of the disease at the cellular and molecular levels. Animal models of asthma remain an important tool with which to dissect disease mechanisms, but they must be improved and refined. The consultation covered a wide range of issues and highlighted the need for collaboration at all levels between research groups and with industry and also between funding agencies. The recommendations made have relevance to everyone involved in basic asthma research. This article describes the recommendations and reviews the specific research issues relating to each of the 7 thematic areas. (J Allergy Clin Immunol 2003;111:251-5.)

Down-regulation of Th2 cytokine expression by glucocorticoids in cultivated human lung mast cells

VOLUME 111, NUMBER 2 using dot blot analysis with the specific antibody, BB1. Ca 2+ fluxes were measured using Fluo-3. Inositol 1,4,5-trisphosphate (IP3) was measured by radio-receptor binding assay. RESULTS: Thrombin (250 U/ml) and trypsin (10 lag/ml) elevated intracetlular Ca 2§ ([Ca2+]i) in KU812 cells. Selective agonist peptides, to PAR-I (TFLLR, 100 gM) and PAR4 (AYPGKF, 300 ~tM) elevated [Ca2+]i but PAR2 selective peptides (SLIGRL, 50 gM and SLIGKV, 100 gM) caused no stimulation. PAR-I and PAR-4 selective peptides transiently increased IP 3 levels in KU812 cells, mRNA for PAR-I and PAR-4 was detected in KU812 cells and purified human basophils (n=3). Additionally mRNA for PAR-2 and -3 was faintly detected in one donor's basopbils. Agonist peptides failed to stimulate basogranulin release from basophils in four out of five experiments. CONCLUSIONS: These data suggest the expression of PAR-1 and PAR4 by human basophils and KU812 cells. PAR-2 and PAR-3 may be expressed by basophils in some individuals. Selective stimulation of PAR1 or PAR-4 is generally insufficient to induce degranulation. Funding: National Asthma Campaign 4 7 7 Down-regulation of Th2 Cytokine Expression by Glucocorticoids in Cultivated Human Lung Mast Cells J. G. Mohanty, J. M. Abboud, E. S. Schulman; Pulmonary and Critical Care Medicine, Drexel University College of Medicine, Philadelphia, PA. RATIONALE: In allergen-induced asthma, mast cells play a critical role through the release of various mediators including Th2 cytokines. Glucocorticoids are used for treatment of allergic disorders; however their effects on human lung mast cell (HLMC) function have not been ftdly studied. Recently, we developed techniques to culture partially purified HLMC over months using stem cell factor and interleukin (IL)-4, in which HLMC become homogeneous, proliferate and maintain a functional phenotype equivalent to freshly isolated cells. METHODS: HLMC were cultured overnight with or without triamcinolone (10-6 M) to examine its effects on the regulation ofTh2 cytokines expression. HLMC were stimulated by antibody cross-linking of the highaffinity IgE receptor (FceRI). At 20 min post stimulation, percent histamine release (HR) was measured; at 2 hour, total cellular RNA was isolated, and reverse transcriptase/polymererase chain reaction (RT-PCR) was performed to study cytokine gene expression. RESULTS: Spontaneous HR was 20-fold, with concurrent increases in IL-6 mRNA levels and DNA binding activity for key transcriptional regulators of the IL-6 promoter, NF-kB and AP-I. Comparisons of conditioned media and eosinophilfibroblasts co-culture using transwell barriers, indicated cell contact is unnecessary and the soluble nature of the mediators. Antibody neutralization of TGF-13 in the conditioned media produced only a 20% inhibition of fibroblast IL-6 secretion. Interestingly, neutralization of IL-113 and bFGF inhibited the IL-6 response by 60% and 15-20%, respectively. Antibody neutralization results were supported by the induction of fibroblast IL-6 secretion by recombinant IL-II3 (68-fold), TGF-I]I (2.5-tbld), and bFGF (l.5-fold). Neutralization of other potential eosinophil-derived mediators including GM-CSF, PDGF-BB, NGE and IL-4, had an insignificant effect. CONCLUSIONS: Our results suggest a major role for eosinophilderived IL-113, TGF-13 and bFGF in fibroblast activation and eosinophilassociated fibrotic responses, including subepithelial fibrosis in asthma. Funding: NIH, EMS Foundation

Asthma management: how effective is it in the community?

The National Asthma Campaign (NAC) was launched in Australia in 1989 with the major objective of improving asthma management through the implementation of a six-step asthma management plan. The objective of the present study was to analyse the management of asthma in a cohort of adults with self-reported asthma 10 years after the commencement of the NAC. The subjects were participants in the laboratory phase of a cross-sectional epidemiological study conducted in Melbourne in 1999-2000. Participants completed the detailed European Community Respiratory Health Survey, which included specific questions about their asthma management. Participants were included in this analysis if they had a positive response to the question 'Have you ever had asthma?'. This resulted in a total of 435 subjects. Of the subjects with self-reported asthma, over half of the participants reported that a doctor had ever measured their breathing (52.9%). However, only 10.1% of participants reported that they owned a peakflow meter (PFM) and only 13.3% reported that they had ever been given a written action plan. In comparison with data reported from 1993, doctor measurement of lung function has decreased significantly (P < 0.000 1), as has PFM ownership (P < 0.0001) and, importantly, possession of a written action plan (P = 0.0004). Asthma management among adults still falls well short of NAC guidelines. The decline in some key features over recent years suggests that new management and dissemination strategies are required.

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Inhibition of human T-cell responses by allergen peptides.

Of the many significant advances in the field of immunology that have occurred in the last 30 years arguably the most important, at least from a T-cell biologists point of view, has been the definition of major histocompatibility complex (MHC) restriction1 and the crystal structure of human leucocyte antigen (HLA) molecules.2–4 These demonstrations have enabled detailed study of the way in which T cells recognize antigen and also how this process differs from that in B cells. With a few notable exceptions, production of specific immunoglobulin by B cells is T-cell dependent. Furthermore, recruitment of non-lymphoid effector cells into areas of inflammation is a process largely marshalled by the T lymphocyte. It follows therefore that inhibition of T-cell function may have beneficial outcomes in situations in which detrimental immune responses occur and give rise to pathology. Suppression of T-cell function has been achieved with the use of pharmacological agents, such as glucocorticosteroids and cyclosporin, and more recently with biological agents, such as monoclonal antibodies directed against CD3 and CD4. Whilst achieving the desired aim of immunosuppression, these approaches suffer from serious weaknesses, the most obvious of which is a lack of specificity for the antigen(s) which drive the inflammatory process. The same may be said to be true of other therapeutic approaches currently being developed which aim to neutralize the effects of individual mediators in the inflammatory cascade. Here, a notable success has been the use of monoclonal antibodies to tumour necrosis factor (TNF) to treat patients with rheumatoid arthritis.5 However, the long-term consequences of removing individual mediators remain to be seen. Of concern is the recent report of subjects receiving anti-TNF therapy developing a lupus-like syndrome thought to be a direct result of the therapy itself.6 The challenge of introducing specificity into strategies aimed at modulating T-cell responses is one that has been met with considerable success in animal models by the use of peptide epitopes from the antigen in question. Peptide-induced tolerance has been demonstrated in models of experimental autoimmune encephalomyelitis (EAE),7,8 collagen-induced arthritis9 and, more recently, in models of allergic disease. Briner and colleagues sensitized mice to the cat allergen Fel d I and subsequently demonstrated the ability of allergen-derived peptides to inhibit T-cell cytokine and antibody production.10 Hoyne and colleagues demonstrated the ability of peptides from the house dust mite allergen Der p II to down-regulate T-cell and antibody responses to challenge with intact protein and also to prevent sensitization by prior administration.11,12 Bauer administered a dominant T-cell epitope of Bet v I to CBA/J mice either prior to or following sensitization with the whole allergen. No change in antibody isotype was observed but T-cell proliferative responses were inhibited by both treatments.13 More recently, mice sensitized to bee venom allergen phospholipase A2 (PLA2), were treated by intranasal administration of a mixture of three long peptides spanning the entire molecule. A marked reduction in specific immunoglobulin E (IgE) was observed coupled with a decreased interleukin-4 (IL-4) to interferon-γ (IFN-γ) ratio. Pre-administration of peptide resulted in a failure to develop IgE sensitization to subsequent immunization with the whole molecule.14 In addition to animal models, the ability of high-dose peptides to modulate human T-cell responses has also been demonstrated. In vitro studies with human T cells were performed by Lamb and colleagues, who demonstrated the induction of antigen-specific non-responsiveness following the incubation of T-cell clones with supraoptimal doses of specific ligand in the absence of professional antigen-presenting cells.15 Collectively, these studies provided a logical basis for the translation of a peptide-based therapeutic approach in man.

Website of the week: Managing chronic diseases: kids' stuff

When children are considered in the context of chronic diseases, it is often with a view to preventing the problems of adult onset cancer and heart disease. In Britain, the Department of Health has initiated a National School Fruit Scheme for children to “protect them against chronic diseases in later life.” At the website (www.doh.gov.uk/schoolfruitscheme/), statistics show that eating green stuff remains among the least favourite activities of most children: “About half eat no peas and three in five eat no leafy green vegetables.” Sadly, chronic illness is not always confined to a child's distant future. Many children are affected by chronic diseases. The internet can be an ideal means of providing these children with knowledge and support. The National Asthma Campaign website contains a “kids' zone” (www.asthma.org.uk/kidszone/) that offers advice on coping with asthma attacks and attempts to provide answers to questions such as “What is asthma?” and “Why do I have asthma?” The “youth site” of Coeliac UK (www.coeliac.co.uk) combines education with entertainment, interspersing its information with interactive space invaders games. Diabetes UK (www.diabetes.org.uk/manage/teenzone/sort_it.htm) provides information relevant to teenagers. It offers advice on alcohol consumption and interactions between recreational drugs and insulin and glucose levels, along with strategies for gaining independence from protective parents. “Band-aides and Blackboards” (www.faculty.fairfield.edu/fleitas/contents.html) aims to provide age appropriate information for all children with chronic illnesses and to educate others (parents, teachers, other children, etc) on what it's like to grow up with a chronic medical condition. It addresses issues of stigma, fear, and coping at school and in hospital through the use of stories and children's personal accounts. “I have a ‘hidden’ medical problem. Most of the time nobody can see it, but sometimes I get very big bruises because of it,” says 9 year old J J, who has haemophilia. “Band-aides and Blackboards” deserves commendation to all. Could a website that promotes understanding and acceptance of children with chronic illness be more valuable than a Department of Health initiative promoting the consumption of cabbage?

21st-century disease

The number of people suffering from allergic diseases has dramatically increased over the past few decades. Allergy now affects 10–40% of the population in industrialized countries (Neville et al, 1999), and particularly affects young people. About 3.4 million people in the UK have asthma, causing considerable illhealth and loss of productivity, as well as about 1 500 deaths a year (National Asthma Campaign, 1999/2000).

NAC Manchester Asthma and Allergy Study (NACMAAS): risk factors for asthma and allergic disorders in adults.

Asthma and atopic disorders are the most common chronic diseases in the developed countries. Knowledge of the risk factors for these disorders may facilitate the development of preventive strategies aimed at reducing prevalence rates. To investigate the risk factors for asthma and allergic diseases in a large number of adults who are the parents of children in the National Asthma Campaign Manchester Asthma and Allergy Study. All pregnant women and their partners attending "Booking" antenatal clinics were invited to take part in the study. Questionnaire data were collected including the history of asthma and other atopic diseases, pet ownership and smoking habits, and skin prick tests were performed. The prevalence of atopy and the risk factors for asthma and allergic disorders were investigated in all subjects who completed the questionnaire and underwent skin testing. Statistical analysis was carried out using logistic regression. Initially, risk factors were assessed by univariate analysis to see how each potential explanatory variable affected the probability of having allergic disease. Variables were then tested in a forward stepwise multivariate analysis. In 5687 adult subjects there was a very high (48.2%) prevalence of atopy, and 9.7% of subjects had a diagnosis of asthma. In a multivariate regression analysis sensitization to dust mite, cat, dog and mixed grasses were all independently associated with asthma. The odds ratios for current asthma increased with the increasing number of positive skin tests (any two allergens - OR 4.3, 95% CI 3.3-5.5; any three allergens - OR 7.0 95% CI 5.3-9.3; all four allergens - OR 10.4, 95% CI 7.7-14; P < 0.00001). Dog ownership (OR 1.31, 95% CI 1.10-1.57; P = 0.003) and current smoking (OR 1.36, 95% CI 1.15-1.62; P = 0.0004) were significantly and directly associated with "asthma ever". Thirteen per cent of participants reported a history of eczema. In the multivariate analysis the strongest independent associate of eczema was sensitization to dog (OR 1.37, 95% CI 1.14-1.63, P < 0.0001). Apart from dog, the strength of the association between sensitization to common allergens and eczema appeared to be much lower than in the case of asthma. The prevalence of hay fever was high (20.6%), and in the multivariate analysis the association between sensitization to pollen and hay fever was extremely strong (OR 13.6, 95% CI 11.3-16.3; P < 0.0001). The results of the current study emphasize the importance of sensitization to indoor allergens in asthma. However, evidence of a possible direct role of allergen exposure in asthma causation remains unclear.

Changing approaches to asthma management in Australia: effects on asthma morbidity.

Asthma is an important public health issue in Australia and is responsible for significant morbidity and mortality in the community. Recognition of the impact of asthma on the health of Australians, and the apparent failure of new medications to reduce mortality and hospital admission rates resulted in a major review by the stakeholders in asthma care. This led to new approaches to asthma management based on strategic use of asthma medications and the development of the Asthma Management Plan (AMP). The AMP drew together current understanding of asthma to develop a simple stepwise approach to management that could be readily applied in patient management. The National Asthma Campaign (NAC), a coalition of the major stakeholders in asthma care, was launched in 1990 to lead the dissemination of the AMP. In association with other organisations interested in asthma care in Australia, the NAC has developed the AMP, and co-ordinated a decade of education and advocacy about asthma that targeted doctors, health professionals and the general public. These activities have been successful in raising awareness about asthma in the community. However, recent research, while demonstrating the continued uptake of written asthma action plans for asthma and decrease in use of inhaled bronchodilator medications, reported a decrease in use of preventive therapy by people with asthma. These activities have had a sustained impact on asthma-related health outcomes with mortality at the lowest level since 1960 and a decline in hospital readmission rates. This is useful information because there is sound evidence that the prevalence and possibly severity of asthma in children has increased. However, review of management in primary care and among people who present to emergency services with acute asthma suggest that many people continue to manage their asthma poorly. Continued education is needed to build on the progress that has been made. There are opportunities to do this through efforts to integrate general practitioners into the wider health system through the formation of Divisions of General Practice. Recognition of asthma as a health priority area at a national level will help to enhance and maintain awareness of the public health importance of asthma and facilitate the further development of the initiatives begun during the last decade or more.