The prevalence of PFS and prevalence and characteristics of reported food allergy; a survey of UK adults aged 18-75 incorporating a validated PFS diagnostic questionnaire.

BACKGROUND: Pollen-food syndrome (PFS), a food allergy affecting pollen-sensitized individuals, is likely to be the most prevalent food allergy in adults, estimated to affect 50-90% of people allergic to birch tree pollen. OBJECTIVE: A validated PFS diagnostic questionnaire (PFSDQ2) was used to determine the prevalence of PFS and also to characterize those who report reactions to foods. METHODS: Five UK General practices each sent the PFSDQ2 by post to 2000 patients aged 18-75 years randomly selected from their practice database. The validated questionnaire was accompanied by an additional set of questions to ascertain the demographic of the population, the foods involved and the age of onset. RESULTS: There were 3590 subjects who returned completed questionnaires, with an average return rate from each practice of 36% (range 22-47%). Of these, 73 were diagnosed with PFS according to the questionnaire (PFS+ve) giving a population prevalence of 2%. A further 482 subjects reported reactions to foods but did not fulfil the diagnostic criteria for PFS. The greatest prevalence of PFS was in the Croydon (SE England) urban practice (4.1%) and the lowest in the Aberdeen (Scotland) urban practice (0.8%) (P < 0.001).The most frequently reported trigger foods were apples, hazelnuts and kiwifruit and the majority of those with PFS first experienced symptoms below the age of 20 years. PFS+ve subjects were also more likely to be female and have a higher socio-economic status than those who did not report reactions to foods. CONCLUSIONS: The UK prevalence of PFS was 2%, although this varied according to the location of the practice population. The majority of PFS+ve subjects first reported symptoms in their teens. The reported age of onset has important implications for the diagnosis of primary and cross-reactive peanut and tree nut allergies in teenagers and young adults. The continuing rise in aeroallergen sensitization is likely to result in an increased frequency of PFS presenting in both primary and secondary care.

Activity levels after pulmonary rehabilitation - what really happens?

OBJECTIVES: To assess the changes in physical activity in subjects with chronic obstructive pulmonary disease over 6months after pulmonary rehabilitation. DESIGN: Prospective, observational study. Activity was measured over 2-day periods at the end of rehabilitation, and repeated every 6weeks for 6months using the ActivPAL uni-axial accelerometer. These results were compared with the shuttle walking test (SWT) and the St. George's Respiratory Disease Questionnaire (SGRDQ). SETTING: UK community hospital. PARTICIPANTS: Adults completing a community rehabilitation programme. MAIN OUTCOME MEASURE: Time spent standing and mobilising ('uptime'). RESULTS: Of 34 subjects recruited, 28 completed the 6-month study period (mean age 69years, mean forced expiratory volume in 1second 1.3l). Participants wore the monitor for 13.8 to 14.2hours/day. At baseline (post-rehabilitation), participants spent 1.7 [standard deviation (SD) 1.3]hours/day walking and 3.5 (SD 2.6)hours/day standing. Taking the group as a whole, mean uptime decreased marginally by 13.6minutes after 24weeks compared with baseline, with significant individual variability. In all but one subject who showed decreased activity, this was apparent after 6weeks. There were no significant changes in the mean SWT or SGRDQ. Significant associations between total uptime and the SWT were found, but coefficients were weak. It was not possible to predict individual responses from baseline data. CONCLUSION: The accelerometer provides useful supplementary data in patients completing rehabilitation programmes, and the results reveal wide variation. The weak associations between activity data and the SWT suggest that monitors provide additional information. More work is required to determine the factors associated with early deterioration in activity in order to design appropriate interventions.

Asthma Control Questionnaire in children: validation, measurement properties, interpretation.

The Asthma Control Questionnaire (ACQ) has been validated in adults to measure the primary goal of management (minimisation of symptoms, activity limitations, short-acting ß2-agonist use and airway narrowing). The present study evaluated the validity, measurement properties and interpretability of the ACQ in children aged 6-16 yrs. 35 children attended clinic on three occasions (0, 1 and 4 weeks) and completed the ACQ, Mini Paediatric Asthma Quality of Life Questionnaire and the Royal College of Physicians' "Three Questions". Parents completed the Paediatric Asthma Caregiver's Quality of Life Questionnaire. Between visits, children completed the Asthma Control Diary and measured peak expiratory flow. At weeks 1 and 4, clinicians and parents completed Global Rating of Change Questionnaires. All patients completed the study. 19 children were stable between two assessments and provided evidence of good test-retest reliability (intraclass correlation coefficient 0.79). The ACQ was responsive to change in asthma control (p = 0.026) and the mean ± sd Minimal Important Difference was 0.52 ± 0.45. Both cross-sectional and longitudinal correlations between the ACQ and the other outcomes were close to predicted and provided evidence that the ACQ measures asthma control in children. The ACQ has strong measurement properties and is valid for use in children aged 6-16 yrs. In children aged 6-10 yrs, it must be administered by a trained interviewer.

Clinical and economic issues associated with switching between triptans in clinical practice.

Seven oral triptans are now generally available for the acute treatment of migraine, and physicians may sometimes feel under pressure to switch patients from one triptan to another for nonclinical reasons. This commentary article provides advice on what information should be taken into account by the physician before they consider switching one triptan for another. We review recommendations on switching triptans from international guidelines for migraine management and relate these to data from a recently published study on the economic implications of switching triptans in the UK. Controlled clinical studies reveal that most of the oral triptans have broadly similar efficacy profiles. Switching triptans can therefore only be recommended if the patient experiences problems such as lack of efficacy or intolerable side effects following repeated use of the initial triptan. The retrospective database study revealed that most patients who had their triptan switched were subsequently switched again during a 15 month review period, most usually back to their original triptan. Overall, switching a patient's triptan led to increased costs (analysed as costs of medication and the GP consultation) to the healthcare provider. These data indicate that patients should only be switched from one triptan for another for clinical reasons and not for perceived economic reasons, i.e. cost of the medication.

Quality-of-life measures in asthma--do they matter to the GP?

Asthma is a condition which incurs a great cost to the National Health Service, to the economy and above all to the patient in terms of loss of quality of life. Treatments for asthma need to be evaluated for their cost-effectiveness. Traditional outcome measures, such as airflow measurements have their limitations, especially in mild to moderate asthma. Quality-of-life measurements represent the impact of asthma on the everyday lives of asthmatics across the whole disease spectrum. Disease specific quality-of-life questionnaires, such as the Asthma Quality-of-Life Questionnaire (AQLQ), provide reliable instruments in reflecting disease severity, but also in detecting changes in quality of life produced by different asthma treatments. Quality-of-life measures are becoming increasingly important and are end-points of therapeutic asthma trials in primary care, but should be used in conjunction with more surrogate markers of asthma severity such as peak flow.

A within-patient comparison of subcutaneous and oral sumatriptan in the acute treatment of migraine in general practice.

This study compared, for the first time in the United Kingdom, the efficacy and safety of oral 100 mg and subcutaneous 6 mg sumatriptan within a patient for the acute treatment of migraine. The patient's preference for the two formulations of sumatriptan were also recorded. The study was a multicentre, randomized, open, crossover design with an optional open parallel group extension. Individual attacks were treated with one formulation only. Over 70% of patients who treated attack 1 in both treatment periods of the crossover phase reported headache relief with each formulation at 4 h. Only 3% of patients failed to respond to at least one of the formulations at this time point. At the end of the crossover phase patient preference for the injection more than doubled from the pretreatment level in those patients who were previously naive to sumatriptan. During the optional phase of the study, 38% of patients chose to treat some attacks with oral and some with subcutaneous sumatriptan. The main reason for choosing injection was speed of relief, whilst convenience was the major reason for the use of the tablet.

Management of acute asthma attacks associated with respiratory tract infection: a postal survey of general practitioners in the U.K.

Asthma attacks in general practice are frequently associated with respiratory tract infection. The aim of this study was to examine how U.K. general practitioners (GPs) might use oral steroids and antibiotics in such situations. The timing of follow-up and use of self-management plans were also examined. A postal questionnaire was sent to all 205 GP principals in Bath Health District, U.K. in February and March 1993. Respondents were asked questions regarding the management of an adult and a child presenting with acute asthma associated with respiratory tract infection. Replies were received from 185 of 205 (90%) doctors approached. Antibiotics would have been prescribed by 119 of 179 (66%) doctors for the adult and 98 of 169 (58%) doctors for the child. The modal initial dosage of oral prednisolone was 40 mg for the adult and 30 mg for the child, and modal duration of oral steroid dosage was 5 days for both adult and child. Planned follow-up was mainly doctor initiated within 24 h of initial consultation. There was low reported use of self-management plans (49% for adults and 33% in children over 7 years of age). Antibiotic prescription appears to be common practice by GPs when faced with an acute asthma attack associated with respiratory tract infection. There may also be inadequate duration of oral steroid courses in adults. There is a need to examine further the proper role, if any, of antibiotics in such situations, to determine the optimum dose and course length of oral steroid therapy, and to continue validating the use of self-management plans in acute asthma management.