S.R. Del Giacco

Rhinitis and asthma in athletes: an ARIA document in collaboration with GA2LEN

This consensus document is aimed at reviewing evidence that the rhinits‐asthma links have peculiar features in athletes. Beside a review of epidemological data on the high prevalence of rhinitis and asthma in athletes, the effects on intense physical exercise on the immune system and repiratory functions are discussed, with special reference to the role of allergens and pollutants. In extending the Allergic Rhinitis and its Impact on Asthma (ARIA) recommendations to athletes, the issue is addressed of adapting diagnosis and management to criteria set by the International Olympic Committee (IOC) and regulations adopted by the World Anti‐Doping Agency (WADA).

Exercise‐induced hypersensitivity syndromes in recreational and competitive athletes: a PRACTALL consensus report (what the general practitioner should know about sports and allergy)

Exercise‐induced (EI) hypersensitivity disorders are significant problems for both recreational and competitive athletes. These include EI‐asthma, EI‐bronchoconstriction, EI‐rhinitis, EI‐anaphylaxis and EI–urticaria. A group of experts from the European Academy of Allergology and Clinical Immunology and the American Academy of Allergy Asthma and Immunology met to discuss the pathogenesis of these disorders and how to diagnose and treat them, and then to develop a consensus report. Key words (exercise with asthma, bronchoconstriction, rhinitis, urticaria or anaphylaxis) were used to search Medline, the Cochrane database and related websites through February 2008 to obtain pertinent information which, along with personal reference databases and institutional experience with these disorders, were used to develop this report. The goal is to provide physicians with guidance in the diagnosis, understanding and management of EI‐hypersensitivity disorders to enable their patients to safely return to exercise‐related activities.

EAACI position statement on asthma exacerbations and severe asthma

Asthma exacerbations and severe asthma are linked with high morbidity, significant mortality and high treatment costs. Recurrent asthma exacerbations cause a decline in lung function and, in childhood, are linked to development of persistent asthma. This position paper, from the European Academy of Allergy and Clinical Immunology, highlights the shortcomings of current treatment guidelines for patients suffering from frequent asthma exacerbations and those with difficult‐to‐treat asthma and severe treatment‐resistant asthma. It reviews current evidence that supports a call for increased awareness of (i) the seriousness of asthma exacerbations and (ii) the need for novel treatment strategies in specific forms of severe treatment‐resistant asthma. There is strong evidence linking asthma exacerbations with viral airway infection and underlying deficiencies in innate immunity and evidence of a synergism between viral infection and allergic mechanisms in increasing risk of exacerbations. Nonadherence to prescribed medication has been identified as a common clinical problem amongst adults and children with difficult‐to‐control asthma. Appropriate diagnosis, assessment of adherence and other potentially modifiable factors (such as passive or active smoking, ongoing allergen exposure, psychosocial factors) have to be a priority in clinical assessment of all patients with difficult‐to‐control asthma. Further studies with improved designs and new diagnostic tools are needed to properly characterize (i) the pathophysiology and risk of asthma exacerbations, and (ii) the clinical and pathophysiological heterogeneity of severe asthma.

EAACI consensus statement for investigation of work‐related asthma in non‐specialized centres

Work‐related asthma (WRA) is a relevant problem in several countries, is cause of disability and socioeconomic consequences for both the patient and the society and is probably still underdiagnosed. A correct diagnosis is extremely important to reduce or limit the consequences of the disease. This consensus document was prepared by a EAACI Task Force consisting of an expert panel of allergologists, pneumologists and occupational physicians from different European countries. This document is not intended to address in detail the full diagnostic work‐up of WRA, nor to be a formal evidence‐based guideline. It is written to provide an operative protocol to allergologists and physicians dealing with asthma useful for identifying the subjects suspected of having WRA to address them to in‐depth investigations in a specialized centre. No evidence‐based system could be used because of the low grade of evidence of published studies in this area, and instead, ‘key messages’ or ‘suggestions’ are provided based on consensus of the expert panel members.

Weight loss interventions in asthma: EAACI Evidence‐Based Clinical Practice Guideline (Part I)

Asthma and obesity are chronic multifactorial conditions that are associated with gene–environment interaction and immune function. Although the data are not fully consistent, it seems that obesity increases the risk of asthma and compromises asthma control.

Asthma and dietary intake: an overview of systematic reviews.

Epidemiological research on the relationship between diet and asthma has increased in the last decade. Several components found in foods have been proposed to have a series of antioxidant, anti‐allergic and anti‐inflammatory properties, which can have a protective effect against asthma risk. Several literature reviews and critical appraisals have been published to summarize the existing evidence in this field. In the context of this EAACI Lifestyle and asthma Task Force, we summarize the evidence from existing systematic reviews on dietary intake and asthma, using the PRISMA guidelines. We therefore report the quality of eligible systematic reviews and summarize the results of those with an AMSTAR score ≥32. The GRADE approach is used to assess the overall quality of the existing evidence. This overview is centred on systematic reviews of nutritional components provided in the diet only, as a way to establish what type of advice can be given in clinical practice and to the general population on dietary habits and asthma.

Pathophysiological mechanisms of exercise-induced anaphylaxis: an EAACI position statement

This document is the result of a consensus on the mechanisms of exercise‐induced anaphylaxis (EIAn), an unpredictable and potentially fatal syndrome. A multidisciplinary panel of experts including exercise physiologists, allergists, lung physicians, paediatricians and a biostatistician reached the given consensus. Exercise‐induced anaphylaxis (EIAn) describes a rare and potentially fatal syndrome in which anaphylaxis occurs in conjunction with exercise. The pathophysiological mechanisms underlying EIAn have not yet been elucidated although a number of hypotheses have been proposed. This review evaluates the validity of each of the popular theories in relation to exercise physiology and immunology. On the basis of this evidence, it is concluded that proposed mechanisms lack validity, and it is recommended that a global research network is developed with a common approach to the diagnosis and treatment of EIAn in order to gain sufficient power for scientific evaluation.

Allergy and sports

At the beginning of the third millennium, physicalexercise is often seen as a kind of panacea (a Greekword meaning ‘‘a cure for every sickness’’): there is nodoubt that it induces an increase in an individual’ssocialization and self-esteem, but it also has positivephysiologic and psychologic effects, improving thefunctioning of the cardiovascular, respiratory, andmuscular systems, and leading to modifications indiet. Sports competitions are now an important part ofeconomic, social, and cultural life, and leading athletesrepresent a model to be imitated by the majority ofyoung people and children. Thus, a large proportion ofthe young population practice exercise and sports inorder to achieve the best results from their bodies.Because allergic illnesses in industrialized countriesaffect 10–25% of the population (1), it may reasonablybe hypothesized that this percentage will be the same forathletes and amateurs of various sporting disciplines.Could it be that a well-trained amateur or aprofessional athlete faces some problems of apseudoallergic type when performing physical exercise?Or is it conceivable that an allergic subject can practicesports at the expert level and, indeed, become achampion?These issues will be examined in this review article.

Allergy in severe asthma

It is well recognized that atopic sensitization is an important risk factor for asthma, both in adults and in children. However, the role of allergy in severe asthma is still under debate. The term ‘Severe Asthma’ encompasses a highly heterogeneous group of patients who require treatment on steps 4–5 of GINA guidelines to prevent their asthma from becoming ‘uncontrolled’, or whose disease remains ‘uncontrolled’ despite this therapy. Epidemiological studies on emergency room visits and hospital admissions for asthma suggest the important role of allergy in asthma exacerbations. In addition, allergic asthma in childhood is often associated with severe asthma in adulthood. A strong association exists between asthma exacerbations and respiratory viral infections, and interaction between viruses and allergy further increases the risk of asthma exacerbations. Furthermore, fungal allergy has been shown to play an important role in severe asthma. Other contributing factors include smoking, pollution and work‐related exposures. The ‘Allergy and Asthma Severity’ EAACI Task Force examined the current evidence and produced this position document on the role of allergy in severe asthma.

Responsiveness of human natural killer cells during acute, incremental exercise up to exhaustion

Eight healthy male subjects performed a cycle ergometer incremental exercise up to exhaustion to study possible relationships between excess CO2 production (CO2-exc) and natural killer (NK) cells, measured in terms of concentration (NKabs) and as a percentage of lymphocytes in peripheral blood (NK%). A parabola-like regression equation with its vertex downwards best fit the relationship between CO2-exc at Wmax and the difference between NK cell measurements at the maximum workload (Wmax) and at the workload corresponding to the anaerobic threshold (WAT). For NK cell concentration, the best equation was NKabs (cells/mm3)=248.8413–0.3105 CO2-exc (ml min-1)+0.0001 CO2-exc2 (ml min-1) (p=0.044). For NK cells expressed as a percentage, the best equation was NK(%)=108.7636–0.1414 CO2-exc (ml min-1)+0.00001 CO2-exc2 (ml min-1) (p=0.032). Thus, the higher was the CO2-exc the lower was the increase in both NK cell measurements at Wmax with respect to the value observed at WAT. However, when CO2-exc reached more elevated values, then the direction of this relationship was inverted. It may be concluded that when strenuous exercise is performed, an anti-inflammatory/performance-preserving event takes place, while recovery towards a pro-inflammatory/anti-infection state tends gradually to re-establish when a subject’s anaerobic power becomes too high.