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Intranasal corticosteroids are widely prescribed for the treatment of perennial allergic rhinitis (PAR). The purpose of this study was to evaluate the efficacy and tolerability of intranasal fluticasone furoate, a novel enhanced-affinity glucocorticoid, in patientsor =12 years of age with PAR in a global, randomized, double-blind, placebo-controlled, 6-week study. Patients (n = 302) received fluticasone furoate nasal spray (FFNS) 110 microg or vehicle placebo once daily (q.d.). The primary efficacy measure was mean change from baseline over the 6-week treatment period in daily reflective total nasal symptom score (TNSS). Secondary end points included mean change from baseline in total and individual reflective nasal and ocular symptom scores and in daily peak nasal inspiratory flow (PNIF). FFNS was significantly more effective than placebo in reducing daily reflective TNSS over the treatment period (least square [LS] mean difference, -1.256; p0.001). Significant improvements were also established in total ocular symptom score (LS mean difference, -0.506; p = 0.004 versus placebo) and in all individual nasal (p0.001) and ocular (p0.03) symptoms assessed in a reflective manner. Improvements in daily PNIF were significantly greater with FFNS than placebo (LS mean difference, 8.376 L/minute; p = 0.004). FFNS was well tolerated. In this study, FFNS 110 microg q.d. was well tolerated and effective in reducing the nasal and ocular symptoms of PAR in adult and adolescent patientsor =12 years of age.

There is a marked increase in the prevalence of food allergies. Food allergy can cause fatal anaphylaxis and the victims are most often adolescents and young adults.This article focuses on IgE mediated food allergy and provides a review of the diagnostic and management strategies for food allergy, including a treatment algorithm for anaphylaxis. The role of the general practitioner in food allergy, when to refer to an allergist, and how to support patients with food allergies long term, including survival tips for patients with food allergy, are also discussed.The key management of food allergy is allergen avoidance informed by accurate allergy diagnosis. Inadvertent exposure to food triggers unfortunately does occur and patients need to be confident in prompt self management. Adrenaline must be given for all potentially life threatening food allergy reactions. Anaphylaxis action plans and optimal asthma control are also critical management objectives.

Asthma is prevalent among elderly Australians but is often misdiagnosed and undertreated. Asthma presents with the same clinical features in the elderly as in the younger population.This article identifies current knowledge about the needs of elderly people with asthma, as well as the knowledge gaps currently existing in this area of health care.A significant proportion of elderly people with asthma go undiagnosed. Elderly patients under-report symptoms and attribute breathlessness to age and other comorbidities. Other difficulties include impaired perception of asthma severity, poor medication adherence, physical disability, cognitive dysfunction, and a passive self management approach. These all contribute to poorer asthma outcomes among the elderly. The management of asthma among the elderly is likely to improve if specific needs are addressed with tailored educational interventions and appropriate care.

As increasing numbers of young people with chronic illness reach adulthood, their ongoing medical care must evolve to be delivered in an adult rather than paediatric setting, a process known as transition. Towards this goal, increasing numbers of paediatric and adult hospitals are engaging in processes to promote the continuity of care for young people with chronic illness. Increasing evidence shows that adverse health consequences occur when inadequate transition arrangements are in place. This article draws from the experience of a transition programme emanating from the Royal Children's Hospital, Melbourne and describes the preparation that can ensure effective transition of young people with chronic illness to adult institutions. In paediatric settings, this includes opportunities for young people to be seen medically on their own to encourage independence with health-care goals and ensuring that adequate health information is transferred to the adult service. In adult institutions, understanding the concept of adolescent development will encourage young people's engagement with the new health-care providers to improve health outcomes. Joint clinics between paediatric and adult health-care teams can improve the transfer of individual patient knowledge, promote a collaborative approach to patient care, facilitate continuity of care and build confidence from both medical and patient perspectives. Including patients in decision-making processes around transition services will encourage youth-focused service developments that will help achieve optimal outcomes in young people with chronic illness.

Adherence to asthma medications presents a problem in all age groups, and older people with chronic illnesses such as asthma also have multiple co-morbidities and consequently complex healthcare needs. It has been suggested that older people are also less likely to adhere to medication and treatment than younger people. Although the prevalence of asthma in older people is similar to that of the general population, over two-thirds of those who die from asthma are >50 years of age and there is strong evidence for under-diagnosis. Clinicians therefore face specific challenges in providing healthcare with respect to both asthma diagnosis and treatment in older age groups. Non-adherence to medication can be defined as either 'intentional' or 'unintentional'. Unintentional non-adherence is more likely to be associated with sociodemographic or physical barriers to the use of medication. Intentional non-adherence results from the balance of individual reasoning of risks versus the benefits of taking medication and acceptance of asthma diagnosis. Intentional non-adherence can be addressed through strategies that influence health beliefs and concerns about the adverse effects of medicine. Unintentional adherence can be addressed by assessing and educating the patient in relation to device use and providing education and clear written instructions about medication requirements. However, some barriers to medication use, such as financial ones, may be systematic. Most studies of medication use, efficacy, adverse effects and adherence in patients with asthma primarily involve younger people. Studies of strategies to improve asthma adherence outcomes specifically in older people are urgently needed.

Objective Recent Australian and international legislation requires labeling of wines made by using the potentially allergenic food proteins casein, milk, egg white, or isinglass (fish-derived) where “there is a detectable residual processing aid.” We investigated whether wines fined using these proteins or non–grape-derived tannins (tree-nut derived) can provoke significant clinical allergic reactions (anaphylaxis) in patients with confirmed immunoglobulin E–mediated relevant food allergy. Methods A double-blind, placebo-controlled trial was performed to determine whether allergic reactions followed consumption of Australian commercial wines fined using one or more of the legislation-targeted food proteins. In addition, allergenicity of a larger panel of these wines was evaluated by blood basophil activation. Results No anaphylaxis was induced by wine consumption. Three mild clinical reactions to protein-fined wine and two mild reactions to unfined wine occurred, but there was no statistically significant difference in reaction parameters between subject groups or between processing aids. No pattern of basophil activation correlated with wine type, processing aid, or subject group. Conclusion Wines fined with egg white, isinglass, or non–grape-derived tannins present an extremely low risk of anaphylaxis to fish-, egg-, or peanut-allergic consumers. Although consumption of milk protein-fined wine did not induce anaphylaxis, there were insufficient subjects to determine statistically whether wines fined with milk proteins present a risk to the very rare milk-allergic consumers. In summary, the observed lack of anaphylaxis and basophil activation induced by wines made using the legislation-targeted food proteins according to good manufacturing practice suggests negligible residual food allergens in these wines.

OBJECTIVES: To ascertain what general practitioners' priorities are for achieving optimal outcomes in people with asthma, and the barriers they face in delivering this care. DESIGN: A qualitative study using the Nominal Group Technique (a highly structured meeting to gain information from experts about a particular issue) was conducted between August 2002 and September 2003. GPs in six discussion groups were asked "What do you think is needed to achieve best outcomes for asthma care?" To augment analysis of the discussion, sessions were taped and transcribed. PARTICIPANTS: Forty-nine GPs were recruited: 34 from metropolitan and 15 from rural areas. RESULTS: All groups nominated asthma education for patients and continuing professional education for GPs as major priorities, but they also described educational and structural barriers to achieving these priorities. Other priorities were: medication adherence, facilitating regular patient review, negotiated treatment/management plans, making the correct diagnosis, increased remuneration and consultation time, and safer asthma medications and access to these. Health promotion initiatives and increased public awareness were also priorities. Spirometry was a significant cause of uncertainty. Overall, written asthma action plans were not considered a high priority. CONCLUSIONS: Remarkable consistency was found between GPs' priorities for delivering best asthma care. Our study identified barriers to asthma guideline adherence, including accessible, relevant education for GPs, and structural, time and cost barriers GPs must overcome in providing asthma treatment and patient education.

WHAT WE NEED TO KNOW: Are there differences in symptom interpretation in older people with asthma? What are effective drug delivery strategies in older people to maximise adherence and minimise side effects? How do older people with asthma manage their asthma? Are self-management strategies as appropriate as they are in younger age groups? Do older people with asthma take appropriate steps in an emergency? Do they own or act on asthma action plans? WHAT WE NEED TO DO: Identify the specific barriers that prevent the optimal care of older people with asthma. Address systematic barriers, such as cost and immobility, that reduce access to effective treatments. Ensure older people with asthma receive appropriate asthma treatment. Explore asthma self-management strategies in older people to develop effective algorithms. Educate health professionals to provide optimal asthma treatments and deliver appropriate education designed specifically for older people.

BACKGROUND: Clinically effective subcutaneous allergen-specific immunotherapy (SIT) is associated with altered circulating T cell cytokine production and altered local cytokine responses with increased IL-10 following allergen challenge in target organs. OBJECTIVE: This study aimed to elucidate mechanisms for these T cell changes, by examining surface expression of markers for peripheral tissue trafficking on circulating cytokine-positive T cells following standardized house dust mite- (HDM-) SIT. METHODS: A randomized conventional HDM immunotherapy study was performed on a panel of 12 HDM-allergic subjects. Nine subjects received treatment with conventional HDM immunotherapy using a standardized extract and three subjects were treated by standard pharmacotherapy alone. Symptom and medication scores and allergen-induced cutaneous late-phase responses were assessed before and 9 months after institution of therapy. Before and at 3 and 9 months of SIT, peripheral blood mononuclear cells were cultured for 14 days with HDM extract and CD4+ and CD8+ T cell expression of CD62L, CD49d and CCR5 and production of IL-10, IFN-gamma and IL-4 were analysed by flow cytometry. Allergen-specific T cell proliferation was assessed by 3H-thymidine incorporation. RESULTS: At 9 months, all SIT-treated patients showed reduced symptom scores and late-phase cutaneous responses to HDM compared with baseline levels. The proportions of CD4+ T cells which were IL-10+ were increased (P < 0.01), and the proportions of CD4+ and CD8+ T cells which were IL-4+ decreased (P < 0.05) compared with baseline. CD4+ and CD8+ T cell IFN-gamma production, expression of surface markers for peripheral tissue trafficking and allergen-specific proliferation remained unchanged during SIT treatment. However, increased proportions of CD4+CD62L(-), CD4+CD49d(hi), CD4+CCR5+ T cells expressing IL-10 were detected at 9 months of SIT compared with baseline (P < 0.05). IL-10 staining co-localized with CD4+CD25+ T cells. CONCLUSION: Clinically effective subcutaneous immunotherapy with a standardized HDM Dermatophagoides pteronyssinus preparation results in decreased numbers of IL-4+ T cells and expansion of CD4+IL-10+ T cells expressing a peripheral tissue trafficking phenotype. The co-localization of IL-10+ staining to CD4+CD25+ T cells is consistent with the induction of a T regulatory cell population by SIT.

2004; 21: 166–172.Background. Asthma treatment guidelines currently recommend a ‘therapeutic partnership’to achieve best care. It is frequently assumed that individuals presenting to emergency depart-ments with asthma do not have a good doctor–patient relationship. We asked what is the natureof patients’ relationships with their doctors in those presenting to hospital emergencydepartments for asthma care.Methods. A qualitative study of all consenting individuals aged 18–70 years who presented toa hospital emergency department over 2 months was carried out. Sixty-two participants (19male) engaged in in-depth interviews which were taped, transcribed and underwent thematicanalysis. Questionnaire data were also collected and asthma severity determined.Results. Nearly all patients (61/62) had a doctor whom they saw for their asthma. Patientsmade thoughtful choices on where they sought care according to their needs. Our findingsidentified that perceptions of doctors’ competence, listening to patients and time constraintswere important influences on doctor–patient relationships. Participants had strong expectationsthat their personal disease experience would be acknowledged by their doctors.Conclusion. This group of patients had doctors who cared for their asthma. The acceptabilityof medical care was determined as much by patient choice as by the quality of thedoctor–patient relationship.Keywords. Adherence, asthma, bodily experience, chronic illness, discourse, doctor–patientrelationships.

Objective To explore the reasons why individuals recurrently present with asthma to hospital emergency departments. Design A predominantly qualitative study in which participants were interviewed in-depth about their asthma. Data on medication use, respiratory health and asthma knowledge were also collected, and asthma severity was determined from medical records. Setting A tertiary teaching hospital and a suburban hospital emergency department (ED) from 1 March to 30 April 2000, and a rural hospital ED from 1 July to 31 August 2000. Participants The participation rate was 32% of an initial 195 ED attendees (183 of whom were eligible) aged 18-70 years: 32 had presented to an ED for asthma care on more than one occasion over the preceding 12 months (reattendees), and 29 were non-reattendees. Results Two-thirds (22/32) of reattendees had chronic severe asthma and presentation to ED was deemed appropriate for 18 of these, indicated by recurrent severe asthma attacks despite seeking prior medical intervention. Reasons for re-presentation identified in a third of all reattendees included poor asthma knowledge, and financial and other barriers to medication use. Conclusions We identified potentially preventable issues in about a third of patients (most of whom had mild to moderate asthma) who recurrently presented to EDs for treatment. The remainder of the participants sought emergency asthma treatment appropriately after failing to respond to medical care, and this was frequently in accordance with their asthma management plans.

Bronchial provocation tests provide objective criteria for asthma and exercise-induced bronchoconstriction (EIB) and were recommended to justify the use of inhaled beta2-agonists by athletes at the Winter Olympics 2002. Eucapnic voluntary hyperpnea (EVH) was one test recommended to identify EIB. Provocation with EVH requires a special dry gas mixture limiting its availability. Provocation tests with osmotic aerosols require less expensive equipment that is easily portable. We assessed the sensitivity of a challenge with mannitol to identify responsiveness to EVH in 50 elite summer sport athletes who were unselected if they had respiratory symptoms. Asthma was previously diagnosed by a doctor in 27 subjects, and 21 subjects were currently under treatment for EIB or asthma. The mean predicted FEV1 was 103.6 +/- 10.8%, FVC was 99 +/- 13.3%, and mean forced expiratory flow during the middle half of the FVC was 104 +/- 22.7%. A total of 25 subjects were positive to EVH challenge (mean percentage of fall in FEV1 was 25.4 +/- 15% SD), and 26 subjects had a positive mannitol challenge (geometric mean [95% confidence interval] provoking dose causing a 10% fall in forced expiratory volume in one second [PD10] was 202 mg [134, 300], with 24 of the subjects positive to both challenges). Mannitol had a sensitivity of 96% and specificity of 92% to identify a positive response to EVH and, as such, could be used as an alternative to EVH to identify EIB.

To investigate the effects of inhaler device technique education on improving inhaler technique in older people with asthma. In a randomised controlled trial, device technique education was provided to a sample of 123 adults aged >55 years who had a doctor diagnosis of asthma. The active education group received one-on-one technique coaching, including observation, verbal instruction and physical demonstration at baseline. The passive group received a device-specific instruction pamphlet only. Inhaler technique, including the critical steps for each device type, was assessed and scored according to Australian National Asthma Council (NAC) guidelines. Device technique was scored objectively at baseline and again at 3 and 12 months post education. The majority of participants demonstrated poor technique at baseline. Only 11 (21%) of the active intervention group and 7 (16%) of the passive group demonstrated 100% correct technique. By 3 months 26 (48%) of the active group achieved adequate technique. Improvement in technique was observed in the active group at 3 months (P

To explore the burden of asthma on the lives of people presenting to hospital emergency departments for asthma treatment.A qualitative study. Consenting individuals with asthma who presented to emergency departments were interviewed in-depth, and interviews were taped, transcribed and thematically analysed. Questionnaire data on medication use, respiratory health and asthma knowledge were also collected. Asthma severity was determined from the medical records.A tertiary teaching hospital and a suburban hospital during March and April 2000, and a rural hospital during July and August 2000.Sixty-two participants (19 male and 43 female), aged 18-70 years.The burden of asthma was broad, affecting social life, personal relationships, employment and finances. The cost of asthma medication was an issue for nearly two-thirds of participants. Individuals performed their own "cost-benefit analysis" for medication use, weighing up expense, perceived side effects and potential benefits. As a consequence, several participants chose to alter their medication dose, or not to take prescribed medications. For some participants, asthma directly contributed to diminished employment opportunities.To achieve a therapeutic partnership, doctors need to be aware of the substantial social, personal and financial burden of asthma for their patients. They should also recognise that patients' perceptions of treatment cost may compromise treatment adherence.

Myopathy complicating the therapy of severe asthma has been recently described in several case reports. Twenty-five consecutive patients admitted to the intensive care unit (ICU) at this hospital for mechanical ventilation for severe asthma were studied for the incidence of creatine kinase (CK) enzyme rise and for the development of clinical myopathy. Pharmacologic therapy was standardized, every patient receiving corticosteroids and aminophylline intravenously and salbutamol both nebulized and intravenously. Twenty-two patients received muscle relaxant therapy with vecuronium. In 19 of 25 (76%) of patients there was elevation of CK levels to a median of 1,575 U/L (range, 66 to 7,430) occurring 3.6 +/- 1.5 days after admission. In nine patients there was clinically detectable myopathy. The presence of either myopathy or CK enzyme rise was associated with a significant prolongation of ventilation time. Arterial blood gas measurements on admission to the ICU revealed a pH (mean +/- SD) of 7.07 +/- 0.21, a PaCO2 of 87.2 +/- 32.7, and a PaO2 (with a high FIO2) of 129 +/- 97 mm Hg; however, no correlation was found between the severity of initial metabolic disturbance and the subsequent development of myopathy. There was no association between the type of corticosteroid administered and the subsequent development of myopathy. Patients with myopathy had received a significantly higher total dose of vecuronium when compared with those who did not develop myopathy (p0.001, Kruskal Wallis test). We have therefore found a surprisingly high incidence of CK enzyme rise and myopathy in this group of mechanically ventilated patients with severe asthma.(ABSTRACT TRUNCATED AT 250 WORDS)

Allergic individuals respond to an environmental allergen encounter by producing T-cell cytokines, predominantly IL-4 and IL-5, which in turn drive the production of allergen-specific IgE antibodies and recruitment of an eosinophil-rich inflammatory infiltrate. Allergen-specific immunotherapy (SIT) involves the repeated injection of the allergen to specifically downregulate this predominantly Th2-type immune response. SIT is a clinically proven effective treatment for allergic diseases, including rhinoconjunctivitis and asthma. However, despite having been in clinical practice since early this century, its use remains empirical. Best practice protocols are based on clinical experience and include recommendations for selecting patients for treatment, SIT regimes and avoidance of adverse events. More rational and safer SIT regimes will result from new insights into the underlying immune mechanisms for allergic disease, in particular the critical role of helper T-cells in orchestrating this response. The development of recombinant techniques for producing purified allergens and allergen derivatives has led to a dramatic improvement in the ability to standardise allergen preparations and to develop novel vaccines for allergy treatment. Potential vaccines include short peptides based on dominant T-cell epitopes of allergens, allergen fragments and mutant allergens. All of these preparations are designed to target T-cells without binding IgE and inducing local and systemic side effects. Additional strategies under consideration include DNA vaccines and fusion protein constructs incorporating immunomodulatory elements such as bacterial cell proteins, cytokines and immunostimulatory sequences of DNA. Different forms of allergens are being evaluated for the more practical mucosal administration of allergy vaccines. The identification of recombinant allergens suitable for diagnostic use and the development of reliable laboratory assays, based on T-cell function to monitor clinical efficacy of SIT, are important practical outcomes from this research.

s of Oral Presentation(OP 90) of the XX World Allergy Congress™ 2007, 2-6 December, Bangkok, Thailand

Objective: As previous asthma mortality studies were undertaken between 1986 and 1997, and treatments have evolved since that time, in order to direct future asthma interventions, we investigated the reasons for asthma deaths between 2005 and 2009. Design: We undertook a case series analysis by searching the National Coroners’ Information System using the most recent International Classification of Diseases-10 codes J45 and J46 and the keyword ‘asthma’ as the underlying cause of death. Setting: Records for 283 cases aged 70 years and under were retrieved from each Australian state and territory. Coroner’s findings, autopsy, toxicology and police reports were reviewed to determine: if the team agreed the death was due to asthma and whether the death was preventable or modifiable factors existed? Owing to the likelihood of comorbidities or alternative diagnoses contributing to deaths in those over 70 years of age, this group was excluded. Results: Examination of available data in those aged under 70 years identified risk factors associated with asthma death. These included physical barriers (rural and remote location, institutionalised care), psychosocial issues (social disengagement, mental illness, living alone, being unemployed), smoking, drug and alcohol dependence, allergies, respiratory tract infections, inadequate treatment and delay in seeking help. Conclusions: Our study provides a current assessment of death from asthma across Australia. Further reductions in the rate of asthma deaths will require interventions targeted at the personal, practice and policy levels. Asthma-related health literacy needs to be improved especially among those with episodic asthma. Reforms are also needed to address inequity in healthcare delivery to ‘reach the unreached’. Our study points to the dangers associated with smoking, drug and alcohol use and the consequences of delay in seeking care among those with asthma.

Interleukin-8 is a cytokine which is a powerful neutrophil chemoattractant in vitro. We have investigated the effects of intranasal instillation of human recombinant IL-8 in 8 atopic (4 male) and 8 non-atopic (1 male) donors in a double-blind placebo controlled study. Changes in nasal resistance were monitored by posterior rhinomanometry for 4 hours after challenge. Symptom scores were recorded on a visual analogue scale. Nasal scrapings were taken and stained with Haema-Gurr for differential cell counts. Nasal resistance data in the whole group revealed an increase in nasal resistance 10 min after challenge compared with placebo (p

EDITOR—The life saving effects of adrenaline in severe allergic reactions are well established, so Johnston et al's lesson of the week cautioning against using adrenaline in “non-life threatening” conditions is worrying.1 2 Anaphylaxis or angioedema of the upper airway is life threatening, and avoiding or delaying appropriate treatment is clearly associated with adverse outcomes, …

Objectives: To investigate the perspectives of patients with asthma on the use of an action plan and the implementation of this plan during an asthma attack that culminated in a visit to an emergency department. Design: Qualitative study. Setting: Tertiary teaching hospital, suburban hospital, and rural hospital. Participants: 62 patients aged 18 to 69 years who presented to an emergency department with asthma over a two month period. Results: 29 participants described having action plans given to them by their doctors. Most patients with action plans reinterpreted their plan from the perspective of their own experiences with asthma. 33 patients did not have an action plan, the most common reason being that they had not been given one by their doctor. Some occupational groups were significantly less likely to have been given an action plan by their doctor than others. Most patients with an action plan found them useful for management of their asthma. Conclusions: Action plans were viewed positively by patients. Participants modified their prescribed plan according to their experience of asthma. To facilitate the implementation of a prescribed action plan, doctors need to acknowledge and include the patient9s personal experience of their disease. What is already known on this topic Action plans for the self management of asthma are standard and have been shown to improve patient outcomes and to protect against death from asthma when provided in written form Factors that enable patients with asthma to implement an action plan and their perspectives on the use of such plans have not been explored in an individual context What this study adds Most patients with action plans found them useful Most patients modified their plans according to their perceptions of severity and likely disease outcome Clinicians must engage with a patient9s experience of asthma to facilitate the use of an action plan