Concomitant medication, comorbidity and survival in patients with breast cancer

Between 30% and 70% of patients with breast cancer have pre-existing chronic conditions, and more than half are on long-term non-cancer medication at the time of diagnosis. Preliminary epidemiological evidence suggests that some non-cancer medications may affect breast cancer risk, recurrence, and survival. In this nationwide cohort study, we assessed the association between medication use at breast cancer diagnosis and survival. We included 235,368 French women with newly diagnosed non-metastatic breast cancer. In analyzes of 288 medications, we identified eight medications positively associated with either overall survival or disease-free survival: rabeprazole, alverine, atenolol, simvastatin, rosuvastatin, estriol (vaginal or transmucosal), nomegestrol, and hypromellose; and eight medications negatively associated with overall survival or disease-free survival: ferrous fumarate, prednisolone, carbimazole, pristinamycin, oxazepam, alprazolam, hydroxyzine, and mianserin. Full results are available online from an interactive platform ( https://adrenaline.curie.fr ). This resource provides hypotheses for drugs that may naturally influence breast cancer evolution.

[Cancers: incidence and survival in metropolitan France]

CANCERS

INCIDENCE AND SURVIVAL IN METROPOLITAN France. Incidence and survival rates are key indicators for cancer surveillance. They also help to drive cancer control programs and public health policies. Focusing on the main cancer localisations, this paper describes the latest incidence (2023) and survival (2018) rates, as well as their evolutions since 1990 in metropolitan France. In 2023, the number of new cases of cancer was estimated to be 433 136, of which 57% occurring in men. Both gender considered, the most frequent cancers are: breast cancer (61 214 new cases), prostate cancer (59 885 new cases) and lung cancer (52 777 new cases). Although the « all cancer » incidence rate as remained quite stable for 33 years in men, it has been raising by almost 1% per year in women. Regarding survival, the standardized net survival (SNS) at 5 years shows great disparities among tumor sites, and it is overall higher in women. Cancers with the best prognosis are thyroid cancer (SNS at 5 years: 96%), prostate cancer (93%), skin melanoma (93%) and uterine cancer (74%). On the contrary, a few tumor locations, including the pancreas (SNS at 5 years of 11%), the liver (18%) and the lung (20%) are still associated with a poor prognosis, even if survival rates have increased in most of cancer locations since 1990.

[After cancer: after-eff ects, return to work and the right to forget]

AFTER CANCER

AFTER-EFFECTS. RETURN TO WORK AND THE RIGHT TO FORGET. The ten-year strategy 2021-2030 against cancers makes staying at work or returning to work after cancer a major priority. A growing number of patients are on the job market at the time of their cancer diagnosis, with a potentially long career future. The after-effects of the disease, and the gap between them and the professional world, present them with numerous difficulties. French national cancer institute (INCa) has launched several initiatives to help people stay in work and return to work, in particular to complement the measures developed by the League against Cancer. INCa has set up the «Cancer and Employment» Business Club, a forum for the exchange of best practices and experiences between employers and researchers in the human and social sciences. The «Cancer aide info réseau entrepreneur» (CAIRE) scheme supports self-employed patients in their professional careers, and gives them a voice in their professional ecosystem. Research initiatives are also undertaken. The social repercussions of the disease also include its impact on borrowing capacity, for both personal and business loans. The "right to be forgotten" for cancer sufferers applies 5 years after the end of the therapeutic protocol. A grid completes the system, and in certain cases enables insurances for a loan can be obtained on standard or similar terms, even before this period has elapsed. It also includes other pathologies such as HIV, hepatitis C and cystic fibrosis. Last but not least, health questionnaires have been abolished for loans under €200,000. The role of the health professional is paramount, providing advice and facilitating the completion of documents requested by insurers.

Killing tumor-associated bacteria with a liposomal antibiotic generates neoantigens that induce anti-tumor immune responses

Increasing evidence implicates the tumor microbiota as a factor that can influence cancer progression. In patients with colorectal cancer (CRC), we found that pre-resection antibiotics targeting anaerobic bacteria substantially improved disease-free survival by 25.5%. For mouse studies, we designed an antibiotic silver-tinidazole complex encapsulated in liposomes (LipoAgTNZ) to eliminate tumor-associated bacteria in the primary tumor and liver metastases without causing gut microbiome dysbiosis. Mouse CRC models colonized by tumor-promoting bacteria (Fusobacterium nucleatum spp.) or probiotics (Escherichia coli Nissle spp.) responded to LipoAgTNZ therapy, which enabled more than 70% long-term survival in two F. nucleatum-infected CRC models. The antibiotic treatment generated microbial neoantigens that elicited anti-tumor CD8+ T cells. Heterologous and homologous bacterial epitopes contributed to the immunogenicity, priming T cells to recognize both infected and uninfected tumors. Our strategy targets tumor-associated bacteria to elicit anti-tumoral immunity, paving the way for microbiome-immunotherapy interventions.

Hypoparathyroidism-related health care utilization and expenditure during the first postoperative year after total thyroidectomy for cancer: a comprehensive national cohort study

Objectives

Hypoparathyroidism is the most common complication of total thyroidectomy for cancer, and requires calcium and/or vitamin D supplementation for an unpredictable period of time. The additional cost associated with this complication has not hitherto been assessed. The aim of this study was to assess the economic burden of postoperative hypoparathyroidism after total thyroidectomy for cancer in France.

Methods

Based on the French national cancer cohort, which extracts data from the French National Health Data System (SNDS), all adult patients who underwent a total thyroidectomy for cancer in France between 2011 and 2015 were identified, and their healthcare resource use during the first postoperative year was compared according to whether they were treated postoperatively with calcium and/or vitamin D or not. Univariate and multivariate cost analyses were performed with the non-parametric Wilcoxon test and generalized linear model (gamma distribution and log link), respectively.

Results

Among the 31,175 patients analyzed (75% female, median age: 52y), 13,247 (42%) started calcium and/or vitamin D supplementation within the first postoperative month, and 2,855 patients (9.1%) were still treated at 1 year. Over the first postoperative year, mean overall and specific health expenditures were significantly higher for treated patients than for untreated patients: €7,233 vs €6,934 per patient (p<0.0001) and €478.6 vs €332.7 per patient (p<0.0001), respectively. After adjusting for age, gender, Charlson Comorbidity index, ecological deprivation index, types of thyroid resection, lymph node dissection and complications, year and region, the incremental cost of overall health care utilization was €142 (p<0.004).

Conclusion

Our study found a significant additional cost in respect of health expenditures for patients who had hypoparathyroidism after thyroidectomy for cancer, over the first postoperative year. Five-year follow-up is planned to assess the impact of more severe long-term complications on costs.

Abstract P3-07-06: Comedications at Breast Cancer diagnosis impact overall survival: results from the ADRENALINE (Atlas for DRug and brEast caNcer survivAL INtEraction) study (n=235,368)

Background: More than half of Breast Cancer (BC) patients take chronically used non-cancer treatments (denoted as comedications) at BC diagnosis. Epidemiological evidence has reported that several non-cancer treatments may modify BC risk, BC recurrence, and overall survival (OS). The ADRENALINE project (Atlas for DRug and brEast caNcer survivAL INtEraction) analyses the impact of the use of each commonly prescribed non-cancer treatment at BC diagnosis on OS using the French social security system data on a comprehensive cohort of French BC patients. Methods: We identified all women diagnosed with an incident BC treated with surgery in France from 2011 to 2017 and affiliated to the general health insurance scheme. Women with concomitant cancer or metastases at diagnosis were discarded from the analyses. Comedication intake was defined as the delivery in pharmacy of at least 3 months of full treatment (e.g. 90 pills) the 6 months preceding BC diagnosis. A Cox proportional hazard model was used to estimate the hazard ratio (HR) for each molecule. The model was adjusted on more than 100 confounding variables: social factors, comorbidities and other comedications by Inverse Probability of Treatment Weighting (IPTW). We assumed that the adjustment was sufficient to control for confounding if the standardized mean difference of each confounder after adjustment did not exceed 0.1. Molecules which did not pass the adjustment quality test were discarded. Results: Overall, 235,368 patients were included in the study. Among 219 selected drugs, 91 passed the adjustment quality test. The full set of results is available on a web application (https://adrenaline.curie.fr). Several drugs or drug classes were associated with an improved survival: statins (e.g. rosuvastatin, HR=0.65, p&lt; 0.001); proton-pump inhibitors (HR=0.93; p=0.002); or beta-blocking agents (atenolol, HR=0.78, p=0.003). Conversely, anti-anemic preparations (folic acid and ferrous sulfate) had a significant deleterious effect (HR = 1.63; p&lt; 0.001). Drugs from the same therapeutic class, could have different effects: within benzodiazepines, bromazepam was protective (HR = 0.91; p = 0.038) while oxazepam was deleterious (HR = 1.37; p &lt; 0.001). Conclusion: ADRENALINE reports the impact on BC survival of 219 widely prescribed drugs. It can be used to identify molecules with a potential protective or deleterious effect relative to BC. Some of them are currently under mechanistical investigation within a drug screening program. This atlas highlights candidates to drug-repurposing trials or pharmacovigilance warnings, and will be extended to cancers of other localizations in a near future.

Citation Format: Elise Dumas, Beatriz Grandal, Paul Gougis, Sophie Houzard, Aurélien Latouche, Aullène Toussaint, Samar Alsafadi, Judith Abecassis, Lidia Delrieu, Thierry Dubois, Nadir Sella, Marc Espie, Bernard Asselain, Annabelle Ballesta, Benjamin Marande, Eric Daoud, Enora Laas, Amyn Kassara, Floriane Jochum, Elaine Del Nery, Elodie Anthony, Christine Le Bihan-Benjamin, Philippe-Jean Bousquet, Chloé-Agathe Azencott, Fabien Reyal, Anne-Sophie Hamy. Comedications at Breast Cancer diagnosis impact overall survival: results from the ADRENALINE (Atlas for DRug and brEast caNcer survivAL INtEraction) study (n=235,368) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-07-06.

Abstract 1022: Disparities in accessibility to oncology care centers in France

Background: Cancer caused nearly 10 million deaths in 2020. While most of the ongoing research focuses on finding new treatments, accessibility to oncology care receives less attention. However, access to health services plays a key role in cancer survival. Spatial accessibility methods have been successfully applied to measure accessibility to primary care. Yet, little research to date focused on oncology care specifically.

Methods: We focused on all care centers with medicine, surgery, or obstetric activity in metropolitan France. We propose a clustering algorithm to automatically label the hospitals in terms of oncology specialization. Then, we computed an accessibility score to these hospitals for every municipality in metropolitan France. Finally, we proposed an optimization algorithm to increase the oncology accessibility by identifying centers which should increase their capacity.

Results: We labelled 1,662 care centers into 8 clusters. Half of them were eligible for oncology care and 118 centers were identified as experts. We computed the oncology accessibility score for 34,877 municipalities in metropolitan France. Half of the population lived in the top 20% accessibility areas, and 6.3% in the bottom 20% zones. Accessibility was higher near dense cities, where the experts care centers were located. By combining the care centers clusters and the accessibility distributions, our optimization algorithm could identify hospitals to grow, to reduce accessibility disparities.

Conclusion: Our method made it possible to quantify oncology care accessibility across all metropolitan France, as well as to make suggestions on where to increase hospital capacity to improve accessibility, especially in more populated suburban areas. Our approach was deliberately non-specific to cancer type nor to the kind of stays, but it could be adapted to more specific scenarios. We packaged our method into a web application allowing the users to run the algorithms with various parameters and visualize the results.

Citation Format: Eric Daoud, Anne-Sophie Hamy, Elise Dumas, Lidia Delrieu, Beatriz Grandal, Christine Le Bihan-Benjamin, Sophie Houzard, Philippe-Jean Bousquet, Judicael Hotton, Aude-Marie Savoye, Christelle Jouannaud, Chloé-Agathe Azencott, Marc Lelarge, Reyal Fabien. Disparities in accessibility to oncology care centers in France [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1022.

The French Early Breast Cancer Cohort (FRESH): A Resource for Breast Cancer Research and Evaluations of Oncology Practices Based on the French National Healthcare System Database (SNDS)

Simple Summary

Because of an important disparity of care pathways and quality of care among women diagnosed with an early-stage breast cancer, we aimed to create a unique cohort of patients including all French women aged 18 years or over, treated by surgery and registered in the general health insurance coverage plan. After aggregating and annotating medico-administrative data on 235,368 early breast cancer patients, we open up perspectives for research on adverse effects, morbidity, mortality, the monitoring of care consumption, or medical-economic studies. We describe data sources, inclusion, and exclusion criteria, basic descriptive analyses, and longitudinal trends over time.

Abstract

Background: Breast cancer (BC) is the most frequent cancer and the leading cause of cancer-related death in women. The French National Cancer Institute has created a national cancer cohort to promote cancer research and improve our understanding of cancer using the National Health Data System (SNDS) and amalgamating all cancer sites. So far, no detailed separate data are available for early BC. Objectives: To describe the creation of the French Early Breast Cancer Cohort (FRESH). Methods: All French women aged 18 years or over, with early-stage BC newly diagnosed between 1 January 2011 and 31 December 2017, treated by surgery, and registered in the general health insurance coverage plan were included in the cohort. Patients with suspected locoregional or distant metastases at diagnosis were excluded. BC treatments (surgery, chemotherapy, targeted therapy, radiotherapy, and endocrine therapy), and diagnostic procedures (biopsy, cytology, and imaging) were extracted from hospital discharge reports, outpatient care notes, or pharmacy drug delivery data. The BC subtype was inferred from the treatments received. Results: We included 235,368 patients with early BC in the cohort (median age: 60 years). The BC subtype distribution was as follows: luminal (80.2%), triple-negative (TNBC, 9.5%); HER2⁺ (10.3%), or unidentifiable (n = 44,388, 18.9% of the cohort). Most patients underwent radiotherapy (n = 200,685, 85.3%) and endocrine therapy (n = 165,655, 70.4%), and 38.3% (n = 90,252) received chemotherapy. Treatments and care pathways are described. Conclusions: The FRESH Cohort is an unprecedented population-based resource facilitating future large-scale real-life studies aiming to improve care pathways and quality of care for BC patients.

Trajectories of adherence to adjuvant endocrine therapy for 5 years in women with breast cancer

Background

Adjuvant endocrine therapy (AET) is a daily oral medication prescribed for women with hormone-sensitive breast cancer (BC) to reduce recurrence and mortality risks. However, many women do not take AET daily or do not persist with AET for the recommended duration of at least 5 years. Our aims were to identify: 1) trajectories of AET adherence for the 5 years; 2) factors associated with these trajectories.

Methods

The French Cancer Cohort includes data on hospitalizations, ambulatory care and drug claims for all cancers diagnosed in France (SNDS database). Women diagnosed with a 1st non-metastatic BC in 2011 who had ≥ 1 AET claim within 12 months of surgery were included. For each woman, we estimated the monthly proportion of days covered (PDC) by an AET for 5 years after the first AET. Monthly PDCs were used to model AET adherence trajectories using group-based trajectory modeling. Statistical criteria were used to assess the suitability of the selected model. The factors associated with the trajectories were identified using multinomial logistic regressions.

Results

33,260 women were included. A 6-trajectory model was selected: 1) Stop of AET in the 1st year (6.6%), 2) Adherence for 1 year and stop (5.7%), 3) Adherence for 2.5y and stop (6.3%), 4) High adherence for 4.5y and stop (8.3%), 5) Sub-optimal adherence for 5y (4.3%), 6) Very high adherence for 5y (68.8%). Factors associated with non-adherence trajectories are mainly extreme age (&gt;70y) and switch in AET.

Conclusions

About 70% of women had an optimal adherence for 5 years. Our results showed that women who changed AET during the treatment course were at higher risk of non-adherence. Among non-adherent women, the switch in AET is frequent and probably often related to the management of side effects. Interventions to detect and manage these side effects may help to support women with AET use. Effective management of these effects during all the 5 years could be needed to maintain adherence.

Key messages

About 70% of women had an optimal adherence for 5 years. Women who changed AET during the treatment course were at higher risk of non-adherence.

Access to inpatient palliative care among cancer patients in France: an analysis based on the national cancer cohort

Background

Closely linked to the concept of supportive care, the integrated model of palliative care (PC) implies identifying, assessing and treating physical and psychological suffering as early as needed, irrespective of patient characteristics. In France, as in the most southern European countries, little is known about the proportion of cancer patients who have access to PC. Accordingly, we aimed in this study to estimate the proportion of cancer patients in France who have access to inpatient PC, and to explore associated factors. We carried out a nationwide retrospective cohort study using data from the French national health system database (SNDS) for all individuals diagnosed with cancer in 2013 and followed between 2013 and 2016. We compared patients who had inpatient PC with those who did not.

Results

Of the 313,059 cancer patients included in the national French cancer cohort in 2013, 53,437 (17%) accessed inpatient PC at least once between 2013 and 2016, ranging from 2% in survivors to 56% in the deceased population. Multivariate logistic regression revealed that women and younger patients (18–49 years old) were less likely to access inpatient PC while patients with a greater number of comorbidities, metastatic cancer, or cancer of the nervous system, were more likely to have done so.

Conclusions

A negligible proportion of cancer survivors accessed inpatient PC. More research and training are needed to convince healthcare providers, patients, and families about the substantial benefits of PC, and to promote better integration of PC and oncology.

Correlation between work impairment, scores of rhinitis severity and asthma using the MASK-air® App

BACKGROUND

In allergic rhinitis, a relevant outcome providing information on the effectiveness of interventions is needed. In MASK-air (Mobile Airways Sentinel Network), a visual analogue scale (VAS) for work is used as a relevant outcome. This study aimed to assess the performance of the work VAS work by comparing VAS work with other VAS measurements and symptom-medication scores obtained concurrently.

METHODS

All consecutive MASK-air users in 23 countries from 1 June 2016 to 31 October 2018 were included (14 189 users; 205 904 days). Geolocalized users self-assessed daily symptom control using the touchscreen functionality on their smart phone to click on VAS scores (ranging from 0 to 100) for overall symptoms (global), nose, eyes, asthma and work. Two symptom-medication scores were used: the modified EAACI CSMS score and the MASK control score for rhinitis. To assess data quality, the intra-individual response variability (IRV) index was calculated.

RESULTS

A strong correlation was observed between VAS work and other VAS. The highest levels for correlation with VAS work and variance explained in VAS work were found with VAS global, followed by VAS nose, eye and asthma. In comparison with VAS global, the mCSMS and MASK control score showed a lower correlation with VAS work. Results are unlikely to be explained by a low quality of data arising from repeated VAS measures.

CONCLUSIONS

VAS work correlates with other outcomes (VAS global, nose, eye and asthma) but less well with a symptom-medication score. VAS work should be considered as a potentially useful AR outcome in intervention studies.

Cancer and end of life: the management provided during the year and the month preceding death in 2015 and causes of death in France

PURPOSE

The management of cancer patients at the end of life in France and their causes of death are not well known.

METHODS

People managed for cancer in 2014-2015, who died in 2015 and who were covered by the national health insurance general scheme (77% of the French population) were selected from the national health data system in order to analyze the health care reimbursed during the year and the month before their death.

RESULTS

This study included 125,497 people (mean age 73 years, SD 12.5) managed for cancer: colorectal: 12%, lung: 18%, prostate: 9%, breast: 8% and other: 62%. Almost 67% of people died in short-stay hospitals (SSH), 8% died in rehabilitation units (Rehab), 4% died in hospital at home (HaH), 5% died in skilled nursing homes (SNH) and 15% died at home or another place. The mean annual duration of all types of hospitalization was 70 days (SD 66) and 59% of patients had received hospital palliative care (HPC). During the last month of life, 42% of people had attended an emergency department at least once and people who had received HPC were less often admitted to an intensive care unit (10% versus 23%, 15% overall). During the month before death, 17% of patients had received intravenous chemotherapy (lung 23%, breast 21%) and 9% had received a pharmacy reimbursement for another form of chemotherapy (prostate 24%, breast 19%). The main cause of death was a tumour for 81% of patients: after management of lung cancer in 91% of cases, breast cancer in 81% of cases, colorectal cancer in 76% of cases and prostate cancer in 63% of cases.

CONCLUSIONS

Cancer management and death mostly occurred in SSH in France. Cancer patients frequently attend the emergency department and frequently receive chemotherapy during the last month of life. These data continue to contrast with those observed in Scandinavian- and English-speaking countries, in which management of the end of life at home is preferred.

[Return to work after a cancer diagnosis]

Given the chronicity of cancer, its related treatments and sequalae, more attention has been paid to questioning the living conditions of cancer survivors. In the early 2000s, research have highlighted the occupational difficulties faced by cancer survivors in the first two years after diagnosis. In the line of these, this article aims to provide clinicians with information on the situation within the five years following cancer diagnosis, based on results of the VICAN5 survey. We explored three main themes: the differences between salaried and self-employed workers, the main sequelae related to the disease or the treatments, having an impact on the working lives of people concerned, and finally, the workstation layouts and their effect on job retention. The main objective is to make clinicians, who may be involved in supporting professionally active patients, aware of the difficulties that these later may encounter. Clinicians need to keep in mind the specific constraint faced by self-employed individuals since they are more likely to reduce their sick leave for financial reasons or for the functioning of their company. They also need to pay more attention to the patient-reported sequalae in order to ensure an adequate care, especially for fatigue and chronic neuropathic pain that can strongly affect his/her professional life. Finally, the clinician who is aware of the effectiveness of workstation layouts will be able to inform and to support his/her patient more precisely.

[Insurability and history of cancer]

At the instigation of the Aeras convention -Insuring and borrowing with an aggravated health risk - and the 2014- 2019 Cancer Plan, the Law of 26 January 2016 introduces the « right to be forgotten » for people with cancer. Thus, people wishing to take out an insurance policy for a mortgage or consumer credit do not have to declare their cancer 10 years after the end of the therapeutic protocol, in the absence of relapse. This period is reduced to 5 years for cancers occurring before the age of 18 years. Associated with this right, the « reference grid » identifies situations for which insurance will be granted without surcharge or exclusion of guarantee, or under conditions that are close to standard conditions. This concerns both cancer -breast, thyroid, prostate cancers ...- and noncancer diseases -HIV, hepatitis C, cystic fibrosis ...-. Through his relationship with his patient, the doctor plays a key role in providing the best insight and helping him in his efforts.

[Incidence, mortality and prevalence of cancers in metropolitan France]

Incidence, mortality and prevalence of cancers in metropolitan France. About 400,000 new people are diagnosed with cancer every year in metropolitan France, including 53.5% men and 46.5% women. Cancer is also the cause of almost 150,000 annual deaths of which 56% occur in men and 44% in women. Nearly 3.8 million people (1.8 million men and 2.0 million women) aged 15 and over have had cancer during their lifetime and are alive in 2017, or 7.0 % of the population aged 15 and over.

French Medico-Administrative Data to Identify the Care Pathways of Women With Breast Cancer

BACKGROUND

Study of the care pathways is an important topic for care planning, as well as to observe guidelines application. This study aimed to describe care pathways and the period of time between treatments of women with breast cancer (BC), at a population level.

MATERIALS AND METHODS

Women with in situ, local and regional BC who were hospitalized and newly treated in 2012 were included and followed for 1 year. Care pathways were described, focusing on surgery (partial mastectomy [PM], total mastectomy [TM]), chemotherapy, and radiotherapy. The periods of time between treatments were measured and compared with the guidelines.

RESULTS

The study involved 52,128 women. The most common care pathways among the 2845 women with in situ BC were PM-radiotherapy (46.7%) and TM (28.5%). Among the 41,470 women with local BC, they were: PM-radiotherapy (44.8%) or PM-chemotherapy-radiotherapy (16.0%). The 7813 women with regional BC had similar care pathways, although chemotherapy was given more frequently (73%). The periods of time between surgery and chemotherapy were in accordance with the guidelines for 98% of the women; those between surgery and radiotherapy were affected by adjuvant chemotherapy. Finally, the time between chemotherapy and radiotherapy was longer than recommended for 40% of the women.

CONCLUSION

The French medicoadministrative databases allow the study, at a national population level, of the care pathways and periods of time between treatments of women with BC according to the stage of the disease. They were close to the guidelines, although an improvement is highly necessary.

Building Bridges for Innovation in Ageing: Synergies between Action Groups of the EIP on AHA

The Strategic Implementation Plan of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) proposed six Action Groups. After almost three years of activity, many achievements have been obtained through commitments or collaborative work of the Action Groups. However, they have often worked in silos and, consequently, synergies between Action Groups have been proposed to strengthen the triple win of the EIP on AHA. The paper presents the methodology and current status of the Task Force on EIP on AHA synergies. Synergies are in line with the Action Groups' new Renovated Action Plan (2016-2018) to ensure that their future objectives are coherent and fully connected. The outcomes and impact of synergies are using the Monitoring and Assessment Framework for the EIP on AHA (MAFEIP). Eight proposals for synergies have been approved by the Task Force: Five cross-cutting synergies which can be used for all current and future synergies as they consider overarching domains (appropriate polypharmacy, citizen empowerment, teaching and coaching on AHA, deployment of synergies to EU regions, Responsible Research and Innovation), and three cross-cutting synergies focussing on current Action Group activities (falls, frailty, integrated care and chronic respiratory diseases).

ARIA 2016: Care pathways implementing emerging technologies for predictive medicine in rhinitis and asthma across the life cycle

The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization workshop in 1999. The initial goals were (1) to propose a new allergic rhinitis classification, (2) to promote the concept of multi-morbidity in asthma and rhinitis and (3) to develop guidelines with all stakeholders that could be used globally for all countries and populations. ARIA—disseminated and implemented in over 70 countries globally—is now focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK [MACVIA (Contre les Maladies Chroniques pour un Vieillissement Actif)-ARIA Sentinel NetworK] uses mobile technology to develop care pathways for the management of rhinitis and asthma by a multi-disciplinary group and by patients themselves. An app (Android and iOS) is available in 20 countries and 15 languages. It uses a visual analogue scale to assess symptom control and work productivity as well as a clinical decision support system. It is associated with an inter-operable tablet for physicians and other health care professionals. The scaling up strategy uses the recommendations of the European Innovation Partnership on Active and Healthy Ageing. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health and social inequalities incurred by the disease.

Comparison of outcome measures in allergic rhinitis in children, adolescents and adults

BACKGROUND

Grass pollen-induced allergic rhinoconjunctivitis (AR) is very common worldwide. However, its symptoms may vary with the patient's age. The present study compared symptom profiles and quality of life (QoL) in children, adolescents and adults with grass pollen-induced AR.

METHODS

This was a four-week, multicentre, observational study of children (aged 6-11), adolescents (12-17) and adults (18-65) consulting specialist physicians in France. The management of AR was at the physicians' discretion. Participants regularly rated their symptoms (the rhinoconjunctivitis total symptom score (RTSS) and a visual analogue scale (VAS)) and QoL (the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ).

RESULTS

A total of 806 patients (253 children, 250 adolescents and 303 adults, of whom 83.5% suffered from moderate-to-severe, persistent AR) provided data for at least the first 2 weeks of the study. Ocular pruritus (the most bothersome symptom in children (35%), adolescents (22%) and adults (16%)) was associated with poor QoL in all groups, whereas nasal obstruction and pruritus were associated with poor QoL in adolescents and children. Over 4 weeks, the weekly mean RTSS and VAS scores fell by around half. This change was associated with an improvement in the RQLQ scores. In all age groups, the VAS score was well correlated with the weekly mean RTSS score (Pearson's r: 0.79-0.88) and moderately correlated with the weekly mean RQLQ score (Pearson's r: 0.64-0.80).

CONCLUSIONS

In moderate-to-severe grass pollen-induced AR, symptom perception differs in children vs. older patients. However, the assessments of treatment outcomes (using the RTSS, VAS and RQLQ) were similar in all age groups.

Operational Definition of Active and Healthy Ageing (AHA): A Conceptual Framework

Health is a multi-dimensional concept, capturing how people feel and function. The broad concept of Active and Healthy Ageing was proposed by the World Health Organisation (WHO) as the process of optimizing opportunities for health to enhance quality of life as people age. It applies to both individuals and population groups. A universal Active and Healthy Ageing definition is not available and it may differ depending on the purpose of the definition and/or the questions raised. While the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) has had a major impact, a definition of Active and Healthy Ageing is urgently needed. A meeting was organised in Montpellier, France, October 20-21, 2014 as the annual conference of the EIP on AHA Reference Site MACVIA-LR (Contre les Maladies Chroniques pour un Vieillissement Actif en Languedoc Roussillon) to propose an operational definition of Active and Healthy Ageing including tools that may be used for this. The current paper describes the rationale and the process by which the aims of the meeting will be reached.

MACVIA-ARIA Sentinel NetworK for allergic rhinitis (MASK-rhinitis): the new generation guideline implementation

Several unmet needs have been identified in allergic rhinitis: identification of the time of onset of the pollen season, optimal control of rhinitis and comorbidities, patient stratification, multidisciplinary team for integrated care pathways, innovation in clinical trials and, above all, patient empowerment. MASK-rhinitis (MACVIA-ARIA Sentinel NetworK for allergic rhinitis) is a simple system centred around the patient which was devised to fill many of these gaps using Information and Communications Technology (ICT) tools and a clinical decision support system (CDSS) based on the most widely used guideline in allergic rhinitis and its asthma comorbidity (ARIA 2015 revision). It is one of the implementation systems of Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA). Three tools are used for the electronic monitoring of allergic diseases: a cell phone-based daily visual analogue scale (VAS) assessment of disease control, CARAT (Control of Allergic Rhinitis and Asthma Test) and e-Allergy screening (premedical system of early diagnosis of allergy and asthma based on online tools). These tools are combined with a clinical decision support system (CDSS) and are available in many languages. An e-CRF and an e-learning tool complete MASK. MASK is flexible and other tools can be added. It appears to be an advanced, global and integrated ICT answer for many unmet needs in allergic diseases which will improve policies and standards.

Clinical relevance is associated with allergen-specific wheal size in skin prick testing

Background

Within a large prospective study, the Global Asthma and Allergy European Network (GA²LEN) has collected skin prick test (SPT) data throughout Europe to make recommendations for SPT in clinical settings.

Objective

To improve clinical interpretation of SPT results for inhalant allergens by providing quantitative decision points.

Methods

The GA²LEN SPT study with 3068 valid data sets was used to investigate the relationship between SPT results and patient-reported clinical relevance for each of the 18 inhalant allergens as well as SPT wheal size and physician-diagnosed allergy (rhinitis, asthma, atopic dermatitis, food allergy). The effects of age, gender, and geographical area on SPT results were assessed. For each allergen, the wheal size in mm with an 80% positive predictive value (PPV) for being clinically relevant was calculated.

Results

Depending on the allergen, from 40% (blatella) to 87–89% (grass, mites) of the positive SPT reactions (wheal size ≥ 3 mm) were associated with patient-reported clinical symptoms when exposed to the respective allergen. The risk of allergic symptoms increased significantly with larger wheal sizes for 17 of the 18 allergens tested. Children with positive SPT reactions had a smaller risk of sensitizations being clinically relevant compared with adults. The 80% PPV varied from 3 to 10 mm depending on the allergen.

Conclusion

These ‘reading keys’ for 18 inhalant allergens can help interpret SPT results with respect to their clinical significance. A SPT form with the standard allergens including mm decision points for each allergen is offered for clinical use.

Integrated care pathways for airway diseases (AIRWAYS-ICPs)

The objective of Integrated Care Pathways for Airway Diseases (AIRWAYS-ICPs) is to launch a collaboration to develop multi-sectoral care pathways for chronic respiratory diseases in European countries and regions. AIRWAYS-ICPs has strategic relevance to the European Union Health Strategy and will add value to existing public health knowledge by: 1) proposing a common framework of care pathways for chronic respiratory diseases, which will facilitate comparability and trans-national initiatives; 2) informing cost-effective policy development, strengthening in particular those on smoking and environmental exposure; 3) aiding risk stratification in chronic disease patients, using a common strategy; 4) having a significant impact on the health of citizens in the short term (reduction of morbidity, improvement of education in children and of work in adults) and in the long-term (healthy ageing); 5) proposing a common simulation tool to assist physicians; and 6) ultimately reducing the healthcare burden (emergency visits, avoidable hospitalisations, disability and costs) while improving quality of life. In the longer term, the incidence of disease may be reduced by innovative prevention strategies. AIRWAYSICPs was initiated by Area 5 of the Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing. All stakeholders are involved (health and social care, patients, and policy makers).

Visual analogue scale in patients treated for allergic rhinitis: an observational prospective study in primary care: asthma and rhinitis

BACKGROUND

Allergic rhinitis (AR) severity is evaluated using scores such as Rhinoconjunctivitis Quality-of-Life Questionnaire (RQLQ) and total symptom score (TSS). However, a simple assessment is needed to enable physicians to evaluate the severity of the AR and the efficacy of the treatment.

OBJECTIVE

The main objective was to validate visual analogue scale (VAS) as a simple quantitative tool to assess the burden of AR in primary care.

METHODS

The study was multi-centre prospective observational conducted in patients consulting general practitioners for symptomatic rhinitis. VAS, RQLQ and TSS6 were assessed at the consultation day and 14 days later, and changes were analysed using paired test. Correlations between VAS, RQLQ and TSS6 were assessed. Cut-off levels for VAS, which discriminate significant from insignificant changes, were established using Receiver Operating Characteristic curves.

RESULTS

A total of 990 patients were included in the study. According to allergic rhinitis and its impact on asthma classification, mild intermittent rhinitis was diagnosed in 20% patients, mild persistent in 17%, moderate/severe intermittent in 15% and moderate/severe persistent in 48%, at the consultation day. At day-14, rhinitis symptoms and QoL improved significantly in almost all patients. Impairment incurred by AR and assessed with VAS improved also. The established cut-off variation of 23 mm for VAS was associated with a cut-off variation of 0.5 for RQLQ. Sensitivity analysis with RQLQ and TSS6 scales confirmed the aptitude of the cut-off value (23 mm) to discriminate changes in symptoms and QoL.

CONCLUSION AND CLINICAL RELEVANCE

The VAS can detect with high sensitivity the variations of symptoms and QoL in patients with AR.

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

Allergic rhinitis (AR) and asthma represent global health problems for all age groups. Asthma and rhinitis frequently coexist in the same subjects. Allergic Rhinitis and its Impact on Asthma (ARIA) was initiated during a World Health Organization workshop in 1999 (published in 2001). ARIA has reclassified AR as mild/moderate-severe and intermittent/persistent. This classification closely reflects patients' needs and underlines the close relationship between rhinitis and asthma. Patients, clinicians, and other health care professionals are confronted with various treatment choices for the management of AR. This contributes to considerable variation in clinical practice, and worldwide, patients, clinicians, and other health care professionals are faced with uncertainty about the relative merits and downsides of the various treatment options. In its 2010 Revision, ARIA developed clinical practice guidelines for the management of AR and asthma comorbidities based on the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system. ARIA is disseminated and implemented in more than 50 countries of the world. Ten years after the publication of the ARIA World Health Organization workshop report, it is important to make a summary of its achievements and identify the still unmet clinical, research, and implementation needs to strengthen the 2011 European Union Priority on allergy and asthma in children.

Severe chronic allergic (and related) diseases: a uniform approach--a MeDALL--GA2LEN--ARIA position paper

Concepts of disease severity, activity, control and responsiveness to treatment are linked but different. Severity refers to the loss of function of the organs induced by the disease process or to the occurrence of severe acute exacerbations. Severity may vary over time and needs regular follow-up. Control is the degree to which therapy goals are currently met. These concepts have evolved over time for asthma in guidelines, task forces or consensus meetings. The aim of this paper is to generalize the approach of the uniform definition of severe asthma presented to WHO for chronic allergic and associated diseases (rhinitis, chronic rhinosinusitis, chronic urticaria and atopic dermatitis) in order to have a uniform definition of severity, control and risk, usable in most situations. It is based on the appropriate diagnosis, availability and accessibility of treatments, treatment responsiveness and associated factors such as comorbidities and risk factors. This uniform definition will allow a better definition of the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes, education and the discovery of novel therapies.

How can we better classify NSAID hypersensitivity reactions?--validation from a large database

BACKGROUND

Hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) is one of the most common drug hypersensitivities. Several clinical subtypes have been distinguished depending on symptomatology (respiratory, cutaneous, anaphylaxis), timing (immediate, delayed), underlying chronic disease (asthma, chronic urticaria) or putative mechanism of the reaction (allergic, nonallergic mediated). The aim of the present study was to better classify the many hypersensitivity reactions to NSAIDs.

METHODS

In the present retrospective study, during an 11-year study period, we collected data from all patients with a proven NSAID hypersensitivity. Reactions were classified according to clinical patterns, chronology, underlying diseases and the results of oral provocation tests into 5 and 7 groups in line with two published classifications, respectively.

RESULTS

Forty-nine and 88 out of 307 reactions (in 122 patients) could not be classified on the basis of the two previously published classifications. We created a new classification which could include all patient reactions.

CONCLUSIONS

Our new classification is more suitable for clinical expression of NSAID hypersensitivity. It allows clinicians to identify patients at a high risk, based on the clinical history and clinical manifestations. Moreover, it is helpful for a better understanding and teaching of these reactions.

Comprehensive allergy work-up is mandatory in cystic fibrosis patients who report a history suggestive of drug allergy to beta-lactam antibiotics

BACKGROUND

In the general population, reports on suspected ß-lactam hypersensitivity are common. After a drug allergy work-up at best 20% of the selected patients are positive. However, these considerations have not been explored in cystic fibrosis patients for whom antibiotics are even more crucial.

METHODS

The study, part of the Drug Allergy and Hypersensitivity (DAHD) cohort, was performed in the regional cystic fibrosis center of Montpellier, France. After identifying patients with a clinical history suggestive of drug allergy to ß-lactams, a complete drug allergy work-up, was carried out according to the EAACI recommendations.

RESULTS

Among the 171 patients involved, 23 reported clinical manifestations potentially compatible with a drug allergy to ß-lactams. After performing the complete drug-allergy work-up, 7 were considered as drug hypersensitive (3 had positive skin tests, 1 a positive provocation test, 3 declined the tests). Excluding the latter 3 patients with incomplete drug allergy work-up, the rate of proven drug allergy was 2.3%.

CONCLUSIONS

Drug allergy to ß-lactams in cystic fibrosis patients is of importance. A full drug allergy work-up is mandatory in case of suspicion, because ß-lactam responsibility is often ruled out.

Epidemiology of cypress pollen allergy in Montpellier

BACKGROUND

Cupressaceae pollen allergy is a worldwide winter pollinosis. Exposure to cypress pollen has increased enormously during recent decades, and cypress pollen allergy has become a major health problem, especially in Mediterranean countries.

OBJECTIVES

We aimed to evaluate the prevalence of cypress pollen sensitization and allergy in the Montpellier area and the symptoms presented by sensitized patients.

METHODS

We included all 6185 consecutive patients who were referred to our center for any allergic disorder during a 36-month period. For each patient, we evaluated skin prick test results, allergy symptoms, pulmonary function test results, and the need for allergen immunotherapy.

RESULTS

We found that 20.7% of patients were sensitized to cypress pollen and 46.4% presented symptoms during the pollen season. The main symptoms were rhinoconjunctivitis and asthma. Oral allergy syndrome to peach was detected in 4% of sensitized and symptomatic patients. Allergen immunotherapy was necessary to control symptoms in 57.9% of cases.

CONCLUSIONS

Cypress pollen allergy is one of the leading causes of respiratory allergy in the Montpellier area. Symptoms are often severe and include pollen-induced asthma. Moreover,many patients need allergen immunotherapy in order to achieve better control of their symptoms.

Asthma in adults and its association with chronic rhinosinusitis: the GA2LEN survey in Europe

BACKGROUND

  The prevalence of asthma and its association with chronic rhinosinusitis (CRS) have not been widely studied in population-based epidemiological surveys.

METHODS

  The Global Allergy and Asthma Network of Excellence (GA(2) LEN) conducted a postal questionnaire in representative samples of adults living in Europe to assess the presence of asthma and CRS defined by the European Position Paper on Rhinosinusitis and Nasal Polyps. The prevalence of self-reported current asthma by age group was determined. The association of asthma with CRS in each participating centre was assessed using logistic regression analyses, controlling for age, sex and smoking, and the effect estimates were combined using standard methods of meta-analysis.

RESULTS

  Over 52,000 adults aged 18-75 years and living in 19 centres in 12 countries took part. In most centres, and overall, the reported prevalence of asthma was lower in older adults (adjusted OR for 65-74 years compared with 15-24 years: 0.72; 95% CI: 0.63-0.81). In all centres, there was a strong association of asthma with CRS (adjusted OR: 3.47; 95% CI: 3.20-3.76) at all ages. The association with asthma was stronger in those reporting both CRS and allergic rhinitis (adjusted OR: 11.85; 95% CI: 10.57-13.17). CRS in the absence of nasal allergies was positively associated with late-onset asthma.

CONCLUSION

  Geographical variation in the prevalence of self-reported asthma was observed across Europe, but overall, self-reported asthma was more common in young adults, women and smokers. In all age groups, men and women, and irrespective of smoking behaviour, asthma was also associated with CRS.

Practical guide to skin prick tests in allergy to aeroallergens

This pocket guide is the result of a consensus reached between members of the Global Allergy and Asthma European Network (GA(2) LEN) and Allergic Rhinitis and its Impact on Asthma (ARIA). The aim of the current pocket guide is to offer a comprehensive set of recommendations on the use of skin prick tests in allergic rhinitis-conjunctivitis and asthma in daily practice. This pocket guide is meant to give simple answers to the most frequent questions raised by practitioners in Europe, including 'practicing allergists', general practitioners and any other physicians with special interest in the management of allergic diseases. It is not a long or detailed scientific review of the topic. However, the recommendations in this pocket guide were compiled following an in-depth review of existing guidelines and publications, including the 1993 European Academy of Allergy and Clinical Immunology position paper, the 2001 ARIA document and the ARIA update 2008 (prepared in collaboration with GA(2) LEN). The recommendations cover skin test methodology and interpretation, allergen extracts to be used, as well as indications in a variety of settings including paediatrics and developing countries.

A statement on cefazolin immediate hypersensitivity: data from a large database, and focus on the cross-reactivities

BACKGROUND

More perioperative cefazolin use has resulted in an increased risk of cefazolin-associated reactions.

OBJECTIVE

The aim of this article is to study immediate reactions to cefazolin and attempt to determine possible allergic cross-reactivity with other ß-lactams using data from the Drug Allergy and Hypersensitivity Database (DAHD).

METHODS

All 25 cefazolin-associated reactions in the DAHD were reviewed. The cases identified were then investigated according to the European Network for Drug Allergy (ENDA) recommendations by skin testing and challenges.

RESULTS

A total of 10 individuals with proven IgE-mediated cefazolin hypersensitivity were identified between January 1999 and July 2009. All the index reactions were compatible with an acute IgE-mediated process, six with anaphylaxis, two with systemic allergic reactions without hypotension, and two with urticaria/angioedema. Cefazolin skin tests were positive in seven individuals and cefazolin challenges were positive in three more individuals. In the eight cefazolin allergic patients who had challenges with other ß-lactams, there was no positive reaction noted.

CONCLUSION AND CLINICAL RELEVANCE

In this cohort of patients with IgE-mediated reactions to cefazolin, a majority tolerated amoxicillin and several patients tolerated other cephalosporins. This implies that the R1 side-chain may play an essential role in IgE-mediated reactions to cefazolin. No clear rule to predict cross-reactivity with other ß-lactams could be determined. More research on IgE-mediated hypersensitivity to cefazolin and other cephalosporins is needed.

Chronic rhinosinusitis in Europe--an underestimated disease. A GA²LEN study

BACKGROUND

Chronic rhinosinusitis (CRS) is a common health problem, with significant medical costs and impact on general health. Even so, prevalence figures for Europe are unavailable. In this study, conducted by the GA²LEN network of excellence, the European Position Paper on Rhinosinusitis and nasal Polyps (EP³OS) diagnostic criteria are applied to estimate variation in the prevalence of Chronic rhinosinusitis (CRS) for Europe.

METHOD

A postal questionnaire was sent to a random sample of adults aged 15-75 years in 19 centres in Europe. Participants reported symptoms of CRS, and doctor diagnosed CRS, allergic rhinitis, age, gender and smoking history. Definition of CRS was based on the EP³OS diagnostic criteria: the presence of more than two of the symptoms: (i) nasal blockage, (ii) nasal discharge, (iii) facial pain/pressure or (iv) reduction in sense of smell, for >12 weeks in the past year--with at least one symptom being nasal blockage or discharge.

RESULTS

Information was obtained from 57,128 responders living in 19 centres in 12 countries. The overall prevalence of CRS by EP³OS criteria was 10.9% (range 6.9-27.1). CRS was more common in smokers than in nonsmokers (OR 1.7: 95% CI 1.6-1.9). The prevalence of self-reported physician-diagnosed CRS within centres was highly correlated with the prevalence of EP³OS-diagnosed CRS.

CONCLUSION

This is the first European international multicentre prevalence study of CRS. In this multicentre survey of adults in Europe, about one in ten participants had CRS with marked geographical variation. Smoking was associated with having CRS in all parts of Europe.

Recommendations for assessing patient-reported outcomes and health-related quality of life in patients with urticaria: a GA(2) LEN taskforce position paper

The aim of this Global Allergy and Asthma European Network (GA(2)LEN) consensus report is to provide recommendations and suggestions for assessing patient-reported outcomes (PROs) including health-related quality of life in patients with urticaria. We recommend that PROs should be used both in clinical trials and routine practice for the evaluation of urticaria patients. We suggest that PROs should be considered as the primary outcome of future clinical trials. Two validated and disease-specific instruments for assessing PROs are available, the urticaria activity score (for symptoms) and the chronic urticaria questionnaire on quality of life CU-Q(2)oL. This latter tool, CU-Q(2)oL, is available in many languages and should be preferred, where available, over more generic instruments for assessing urticaria-specific effects on quality of life. CU-Q(2)oL is only suited for the investigation of patients with chronic spontaneous urticaria. Similar instruments for other forms of urticaria have yet to be developed and validated. Also, tools for assessing other chronic spontaneous urticaria PROs besides quality of life and symptoms are needed.

Patients' satisfaction with diagnostic drug provocation tests and perception of its usefulness

BACKGROUND AND AIM

Although still controversial, drug provocation tests (DPTs) are considered by many as the gold standard for diagnosis of drug hypersensitivity. No studies have addressed the opinion of patients submitted to DPT. We aimed to determine patient satisfaction with diagnostic DPT and their perception of its usefulness.

METHODS

Surveys were supplied to patients submitted to diagnostic DPT in 3 different drug allergy clinics which used the same diagnostic protocols for drug hypersensitivity evaluation. Seventy-three patients (33.6%) were enrolled in Porto (Portugal), 102 (47%) in Montpellier (France) and 42 (19.4%) in Vilnius (Lithuania). The patients filled in a written questionnaire within 15 days after the diagnostic procedure, and satisfaction was assessed on a 1 (very unsatisfied) to 5 (very satisfied) score.

RESULTS

A total of 217 surveys were collected; 144 female patients (66.4%). The most prevalent studied reactions were cutaneous (70.1%), but 17.9% of the patients had had a systemic reaction. β-Lactam antibiotics were the main culprit drugs (44.3%) tested in all centres and 25.3% of the patients had a positive DPT. No patients were unsatisfied (8.8% were neither unsatisfied nor satisfied and the others were satisfied or very satisfied). The level of satisfaction did not depend on the results of the DPT; 207 (95.4%) believed DPTs were useful and almost all the patients would recommend DPTs to others.

CONCLUSIONS

Most patients were satisfied with DPT for diagnostic purposes. Satisfaction with the procedure was independent of the results of the provocation tests and did not depend on the country.

How to design and evaluate randomized controlled trials in immunotherapy for allergic rhinitis: an ARIA-GA(2) LEN statement

Specific immunotherapy (SIT) is one of the treatments for allergic rhinitis. However, for allergists, nonspecialists, regulators, payers, and patients, there remain gaps in understanding the evaluation of randomized controlled trials (RCTs). Although treating the same diseases, RCTs in SIT and pharmacotherapy should be considered separately for several reasons, as developed in this study. These include the severity and persistence of allergic rhinitis in the patients enrolled in the study, the problem of the placebo, allergen exposure (in particular pollen and mite), the analysis and reporting of the study, the level of symptoms of placebo-treated patients, the clinical relevance of the efficacy of SIT, the need for a validated combined symptom-medication score, the differences between children and adults and pharmacoeconomic analyses. This statement reviews issues raised by the interpretation of RCTs in sublingual immunotherapy. It is not possible to directly extrapolate the rules or parameters used in medication RCTs to SIT. It also provides some suggestions for the research that will be needed. Interestingly, some of the research questions can be approached with the available data obtained from large RCTs.

Unmet clinical needs in chronic spontaneous urticaria. A GA²LEN task force report

Chronic spontaneous urticaria, formerly also known as chronic idiopathic urticaria and chronic urticaria (CU), is more common than previously thought. At any time, 0.5-1% of the population suffers from the disease (point prevalence). Although all age groups can be affected, the peak incidence is seen between 20 and 40 years of age. The duration of the disease is generally 1-5 years but is likely to be longer in more severe cases, cases with concurrent angioedema, in combination with physical urticaria or with a positive autologous serum skin test (autoreactivity). Chronic spontaneous urticaria has major detrimental effects on quality of life, with sleep deprivation and psychiatric comorbidity being frequent. It also has a large impact on society in terms of direct and indirect health care costs as well as reduced performance at work and in private life. In the majority of patients, an underlying cause cannot be identified making a causal and/or curative treatment difficult. Nonsedating H₁-antihistamines are the mainstay of symptomatic therapy, but treatment with licensed doses relieves symptoms effectively in < 50% of patients. Although guideline-recommended updosing up to fourfold increases symptom control in many patients, a substantial number of patients have only little benefit from H₁ -antihistamines. Consequently, there is a great need for new therapeutic strategies.

The 2009-2010 H1N1 vaccination campaign for patients with egg allergy in a region of France

We describe our experience of the influenza H1N1 vaccination in patients with egg allergy. All patients tolerated the vaccination in a simple or double dose protocol without any significant allergic reaction in this series.

GA² LEN/EAACI pocket guide for allergen-specific immunotherapy for allergic rhinitis and asthma

This pocket guide is the result of a consensus reached during several GA(2) LEN and EAACI meetings. The aim of the current pocket guide is to offer a comprehensive set of recommendations on the use of immunotherapy in allergic rhinoconjunctivitis and asthma in daily practice. This pocket guide is meant to give simple answers to the most frequent questions of practitioners in Europe, including 'practising allergists', general practitioners and any other physicians with special interest in allergen-specific immunotherapy (SIT). It is not a long or detailed scientific review of the topic. However, the recommendations in this pocket guide were compiled following an in-depth review of existing guidelines and publications, including the 1998 EAACI position paper, the 1998 WHO Position Paper on SIT and the 2001 Allergic Rhinitis and its Impact on Asthma (ARIA). It is also based on the ARIA update 2008 (prepared in collaboration with GA(2) LEN), the 'Sub-lingual Immunotherapy: WAO Position Paper 2009' (from the World Allergy Organisation) and the Methodology paper of ARIA. The recommendations cover patient selection, allergen extract to be used, route of administration of SIT (in particular, sublingual and subcutaneous immunotherapy), and necessary precautions to be followed in using SIT.

Development and implementation of guidelines in allergic rhinitis – an ARIA-GA2LEN paper

The links between asthma and rhinitis are well characterized. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines stress the importance of these links and provide guidance for their prevention and treatment. Despite effective treatments being available, too few patients receive appropriate medical care for both diseases. Most patients with rhinitis and asthma consult primary care physicians and therefore these physicians are encouraged to understand and use ARIA guidelines. Patients should also be informed about these guidelines to raise their awareness of optimal care and increase control of the two related diseases. To apply these guidelines, clinicians and patients need to understand how and why the recommendations were made. The goal of the ARIA guidelines is to provide recommendations about the best management options for most patients in most situations. These recommendations should be based on the best available evidence. Making recommendations requires the assessment of the quality of available evidence, deciding on the balance between benefits and downsides, consideration of patients’ values and preferences, and, if applicable, resource implications. Guidelines must be updated as new management options become available or important new evidence emerges. Transparent reporting of guidelines facilitates understanding and acceptance, but implementation strategies need to be improved.

The very limited usefulness of skin testing with penicilloyl-polylysine and the minor determinant mixture in evaluating nonimmediate reactions to penicillins

BACKGROUND

The contribution of skin testing with penicilloyl-polylysine (PPL) and the minor determinant mixture (MDM) to the diagnosis of hypersensitivity reactions to penicillins differs greatly according to the type of reaction: immediate (occurring within 1 h after the last drug administration) or nonimmediate (occurring more than 1 h after the last drug administration).

OBJECTIVE

To assess the contribution of skin testing with PPL and MDM to the diagnosis of nonimmediate reactions to penicillins.

METHODS

We evaluated 162 adults who had had 232 nonimmediate reactions to penicillins, mostly aminopenicillins, and presented positive skin and/or patch tests to one or more penicillin reagents: PPL, MDM, benzylpenicillin, ampicillin, and amoxicillin, as well as any responsible penicillins.

RESULTS

A total of 157 subjects (96.9%) displayed patch-test and/or delayed-reading intradermal-test positivity to penicillin reagents, which indicates a cell-mediated hypersensitivity; six of them also presented immediate-reading skin-test positivities. All 157 patients with a cell-mediated hypersensitivity were positive to the responsible penicillins (parent drugs); 16 of them also displayed delayed-reading intradermal-test positivity to MDM. Five (3.1%) of the 162 patients displayed only immediate-reading skin-test positivity (four to PPL and one to amoxicillin). Overall, 158 subjects (97.5%) presented positive responses to the responsible penicillins, while only 9 (5.5%) and 17 (10.5%) were positive to PPL and MDM, respectively.

CONCLUSIONS

The contribution of skin testing with PPL and MDM in diagnosing nonimmediate hypersensitivity reactions to penicillins, especially cell-mediated ones, is very limited. This finding could be useful at a time when PPL and MDM are not available in all countries.

Assessment of allergen sensitization in a general population-based survey (European Community Respiratory Health Survey I)

PURPOSE

Exposed to a common environment, the IgE-mediated immune response differs, for instance, among sensitized subjects, some of them reacting toward one allergen (monosensitized) whereas others are sensitized to a wide array of allergens (polysensitized). However, a better phenotypic characterization is needed for epidemiologic studies. Using the data collected during the ECRHS I (European Community Respiratory Health Survey), several assessments of skin prick tests and serum-specific IgE to identify mono- and polysensitized patients were compared.

METHODS

Subjects took part in the ECRHS-I. The CAP-System was used for serum allergen-specific IgE, and allergen-coated Phazet was used for prick tests. Four allergens (Dermatophagoides pteronyssinus, cat, timothy grass, and Cladosporium) were measured using IgE and nine (the same ones plus olive pollen, birch, Alternaria, Parietaria, and ragweed) were skin tested. One to two local allergens were also tested, depending on countries.

RESULTS

Prevalence of sensitization in 11,355 subjects (34.0 [27.9-40.1] years, 49.9% men) ranged from 32.3% (four specific IgE, 19.3% mono- and 13.0% polysensitized) to 41.8% (four specific IgE combined to nine prick tests, 19.6% mono- and 22.2% polysensitized). Concordance between four specific IgE and four prick tests was weak (weighted κ 0.65 [0.64-0.66]). Concordance between seven and nine prick tests was high (weighted κ 0.99 [0.98-1.00]). Local allergens induced small changes in the prevalence of sensitization, and reclassified some subjects from mono- to polysensitized.

CONCLUSIONS

Skin tests or serum-specific IgE may be chosen to identify allergenic sensitivity, mono- and polysensitized subjects without being strictly interchangeable.

Specific recommendations for PROs and HRQoL assessment in allergic rhinitis and/or asthma: a GA(2)LEN taskforce position paper

The GA(2)LEN taskforce on Patient-Reported Outcomes (PROs) and Health-Related Quality of Life (HRQoL) published in 2009 a position paper concerning PROS and HRQoL assessment in clinical trials on allergy. Because of the specificity of this topic in asthma and rhinitis, specific recommendations are needed. The aim of this position paper is to define PROs and their meaning in asthma and rhinitis research, explore the available tools to provide criteria for a proper choice, identify patient-related factor which could influence PROs assessment, define specific recommendations for assessment, analysis and results spreading, underline the unexplored areas and unmet needs. PROs assessment is gaining increasing importance, and it must be performed with a rigorous methodological procedure and using validated tools. This approach enables to better understand patient-related factors influencing clinical trials and real-life management outcomes, identify patients subgroups that can benefit from specific treatment and management plan and tailor treatment to address PROs (not only physician-defined targets) to improve asthma and rhinitis management.