Publications by authors named "Bircan Erbas"

115 Publications

Plasma lipid biomarkers in relation to BMI, lung function, and airway inflammation in pediatric asthma.

Metabolomics 2021 Jun 26;17(7):63. Epub 2021 Jun 26.

Department of Public Health, School of Psychology & Public Health, La Trobe University, Melbourne, Australia.

Introduction: There is limited understanding of how plasma fatty acid levels affect pulmonary function in pediatric years. It has been speculated that polyunsaturated fatty acids influence asthma via anti or pro-inflammatory mechanisms. Metabolomics presents a new and promising resource for identifying molecular processes involved in asthma pathology.

Objectives: We investigated the relationship of plasma fatty acid metabolites as biomarkers of the 'mild-asthma' phenotype and lung function including airway inflammation in children.

Methods: This cross-sectional study involved 64 children (5-12 years, 33 male) with mild-asthma phenotype attending an outpatient pediatric clinic in Athens, Greece. Clinical examination included spirometry (FVC, FEV, FEV/FVC, PEF, FEF) and Fractional exhaled Nitric Oxide (FeNO). Targeted metabolomic profiling was used to quantify plasma fatty acid composition. Associations between lipids and pulmonary function indices were investigated applying linear regression.

Results: Targeted GC-MS identified 25 unique plasma fatty acids in mild-asthmatic children. Linear regression revealed significant associations between linoleic, oleic, erucic, cis-11-eicosenoic, arachidic acids and FEV, FVC, FEV/FVC, PEF, FEF and FeNO in the overweight/obese group, adjusting for age and sex; and in the normo-weight between stearic and arachidic acids versus FEV and FEV/FVC respectively. No associations were observed for arachidonic, α-linolenic, EPA and DHA.

Conclusion: Metabolomics is a novel science that is useful to discover metabolic signatures specific to disease. Evaluation of fatty acid status could assist clinicians in decision-making about a dietary modification that can be used for personalized nutrition therapies to achieve better asthma control, optimum lung function, and therapeutic response in children.
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http://dx.doi.org/10.1007/s11306-021-01811-5DOI Listing
June 2021

Community Response to the Impact of Thunderstorm Asthma Using Smart Technology.

Allergy Rhinol (Providence) 2021 Jan-Dec;12:21526567211010728. Epub 2021 Apr 26.

School of BioSciences, University of Melbourne, Parkville, Australia.

Background: The most severe thunderstorm asthma (TA) event occurred in Melbourne on the 21st November 2016 and during this period, daily pollen information was available and accessible on smart devices via an App. An integrated survey within the App allows users to self-report symptoms.

Objective: To explore patterns of symptom survey results during the period when the TA event occurred.

Methods: Symptom data from the Melbourne Pollen Count and Forecast App related to asthma history, hay fever symptoms, and medication use was explored. A one-week control period before and after the event was considered. Chi-square tests and logistic regression were used to assess associations between sex, age, symptoms, and medication use.

Results: Of the 28,655 responses, during the 2016 pollen season, younger (18 to 40 years) males, with no hay fever and no asthma were the most single and regular responders. During the TA event for new users, sex was only significantly associated with hay fever ( = 0.008) of which 60.2% of females' responses reported having hay fever, while 43% of males' responses did not. Those with mild symptoms peaked during the TA event.

Conclusions: Many individuals completed the survey on the app for the first time during the TA event indicating the potential of digital technologies to be used as indicators of health risk among populations at risk of TA events.
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http://dx.doi.org/10.1177/21526567211010728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8083005PMC
April 2021

Characteristics of emergency patients admitted to hospital with asthma: A population-based cohort study in Queensland, Australia.

Emerg Med Australas 2021 May 15. Epub 2021 May 15.

School of Biomedical Sciences, Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.

Objective: Patient characteristics with exacerbation of asthma accessing care in the ED who are at risk of hospital admission have not been determined in subtropical climates. The objective of the study was to investigate the spatiotemporal burden of asthma hospital admissions across Queensland (QLD) and model risk factors for asthma hospital admission following an ED visit.

Methods: Six years of routinely collected data (2012-2017) from 28 QLD public hospitals were extracted from Queensland Health's Emergency Data Collection. The dataset contained individual, episode-level ED presentations having asthma-like diagnoses, and an indicator of hospital admission, including to short-stay unit (SSU). A generalised additive model was used to examine the risk of asthma hospital admission.

Results: Asthma hospital admissions increased from a weekly median of 79 (interquartile range [IQR] 66-99) in 2012 to 104 (IQR 81-135) in 2017. A higher incidence of asthma hospital admission was observed among males (median age 9, IQR 5-32) in childhood and females in adulthood (median age 32, IQR 11-51). Compared to the state capital Brisbane, the odds of asthma hospital admission ranged from 0.48 (95% CI 0.42-0.54) to 1.34 (95%CI 1.21-1.48) in other regions of QLD.

Conclusion: Asthma hospital admissions appear to be increasing in QLD, largely driven by utilisation of the SSU admissions for asthma. With large variation in both incidence and proportion admitted across different regions, routinely collected data can in part be used to understand risk factors for asthma-related hospital admission following an ED presentation and further inform public health policy development.
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http://dx.doi.org/10.1111/1742-6723.13796DOI Listing
May 2021

Potential role of folate status on pulmonary function in pediatric asthma.

Nutrition 2021 Apr 7;90:111267. Epub 2021 Apr 7.

La Trobe University, School of Allied Health, Department of Dietetics, Nutrition & Sport, Melbourne, Australia; RMIT University, School of Health and Biomedical Sciences, Melbourne, Australia.

Objective: The aim of this study was to explore the relationship between plasma folate status and measures of airway disease (as reflected by spirometry) in children with asthma on a traditional Mediterranean diet. We hypothesized that folate deficiency is associated with lung function impairment in this group of children.

Methods: This cross-sectional study included 64 children with mild asthma (52% boys, mean age 8 ± 2 y) residing in Athens, Greece. Clinical assessments included spirometry and fractional exhaled nitric oxide (FeNO). Plasma 5-methyltetrahydrofolate (5-MTHF) was analyzed using high performance-liquid chromatography assay and examined in participants using quartiles (Q1-Q4).

Results: Of the 64 children, 45.3% were folate deficient (5-MTHF <10 nmol/L). A positive relationship was observed between 5-MTHF and forced vital capacity (FVC; β = 0.79, 95% confidence interval (CI), 0.14-1.44; adjusted P = 0.019), forced expiratory volume in 1s (FEV) (β = 0.78; 95% CI, 0.01-1.55; adjusted P = 0.046), and peak expiratory flow (PEF; β = 1.64; 95% CI, 0.14-3.15; adjusted P = 0.033) in girls only, adjusting for body mass index and regular exercise. Girls with low plasma folate concentrations (Q1), compared with girls with high concentrations (Q4) had 8.64% lower FVC (β = -8.64; 95% CI, -16.18 to -1.09; adjusted P = 0.027), 10.35% FEV (β = -10.35; 95% CI, -18.82 to -1.89; adjusted P = 0.019), and 18.72% PEF (β = -18.72; 95% CI, -36.30 to -1.14; adjusted P = 0.038).

Conclusion: The findings of this study highlighted the potential negative effects of folate deficiency on pulmonary function in girls with asthma, the importance of monitoring folate status in children with asthma, and early prevention strategies.
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http://dx.doi.org/10.1016/j.nut.2021.111267DOI Listing
April 2021

Impact of Individual, Familial and Parental Factors on Adolescent Smoking in Turkey.

Int J Environ Res Public Health 2021 04 2;18(7). Epub 2021 Apr 2.

Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne 3083, Australia.

The burden of adolescent cigarette smoking is substantial. We assess mothers' and fathers' attitudes and behaviours on adolescent smoking using a cross-sectional study of = 707 adolescents. Associations between parental attitudes and behaviours in adolescent smoking were assessed using logistic regression separately for boys and girls. Occasional alcohol use by both parents increased odds of smoking once a day (OR = 2.44, 95% CI 1.26, 4.71, OR = 1.51, 95% CI 0.97, 2.35, respectively). Fathers smoking increased odds for girls (OR = 1.59, 95% CI 1.01, 2.52). A democratic mother decreased odds for boys (OR = 0.32, 95% CI 0.10, 0.93) whereas a protective, demanding mother increased the odds for girls (OR = 8.65, 95% CI 1.38, 54.22). Public health smoking prevention programs could support changing parental behaviours and attitudes in early years to address this burden in countries with authoritarian parenting styles.
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http://dx.doi.org/10.3390/ijerph18073740DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8038305PMC
April 2021

The association between outdoor allergens - pollen, fungal spore season and high asthma admission days in children and adolescents.

Int J Environ Health Res 2021 Feb 21:1-10. Epub 2021 Feb 21.

Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne, Australia.

Periods when asthma admissions peaks have serious implications for asthma sufferers and hospitals. We assessed the association between aeroallergen exposure and childhood asthma peak periods during two grass pollen seasons using the Melbourne Air Pollen Children and Adolescent Health (MAPCAH) study conducted in Melbourne, Australia. Two peak periods were identified. Effect modifications by atopy and sex were considered. All pollen 2 days prior was associated with increased odds of these peak periods. Same day fungal spores, but not pollen, were important. Grass at lag 2 was associated with increased odds 1.03 (95%CI 1.01, 1.05) as was the same day 1.02 (1.00, 1.04) per spore/m for boys. In addition to pollen, fungal spores particularly may result in days of high exacerbations during pollen seasons. Further guidance is needed to better prepare families/carers with information about the increased risk of asthma attacks in children prior to pollen seasons.
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http://dx.doi.org/10.1080/09603123.2021.1885633DOI Listing
February 2021

Association between ambient air pollution and development and persistence of atopic and non-atopic eczema in a cohort of adults.

Allergy 2021 Aug 4;76(8):2524-2534. Epub 2021 Mar 4.

Allergy and Lung Health Unit, The University of Melbourne, Melbourne, Vic, Australia.

Background: There is limited information on risk factors for eczema in adults. Recent evidence suggests that air pollution may be associated with increased incidence of eczema in adults. We aimed to assess this possible association.

Methods: Ambient air pollution exposures (distance from a major road, nitrogen dioxide [NO ], fine particulate matter with an aerodynamic diameter ≤2.5 µm [PM ]) were assessed for the residential address of Tasmanian Longitudinal Health Study participants at ages 43 and 53 years. Eczema incidence (onset after age 43 years), prevalence (at 53 years), and persistence were assessed from surveys, while IgE sensitization was assessed using skin prick tests. The presence or absence of eczema and sensitization was classified into four groups: no atopy or eczema, atopy alone, non-atopic eczema, and atopic eczema. Adjusted logistic and multinomial regression models were fitted to estimate associations between ambient air pollution and eczema, and interaction by sex was assessed.

Results: Of 3153 participants in both follow-ups, 2369 had valid skin prick tests. For males, a 2.3 ppb increase in baselineNO was associated with increased odds of prevalent eczema (OR = 1.15 [95% CI 0.98-1.36]) and prevalent atopic eczema (OR = 1.26 [1.00-1.59]). These associations were not seen in females (p for interaction = 0.08, <0.01). For both sexes, a 1.6 µg/m increase in PM exposure at follow-up was associated with increased odds of aeroallergen sensitization (OR = 1.15 [1.03-1.30]).

Conclusion: Increased exposure to residential ambient air pollutants was associated with an increased odds of eczema, only in males, and aeroallergen sensitization in both genders.
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http://dx.doi.org/10.1111/all.14783DOI Listing
August 2021

Outdoor pollen-related changes in lung function and markers of airway inflammation: A systematic review and meta-analysis.

Clin Exp Allergy 2021 May 18;51(5):636-653. Epub 2021 Feb 18.

Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, Australia.

Background: Experimental challenge studies have shown that pollen can have early and delayed effects on the lungs and airways. Here, we qualitatively and quantitatively synthesize the evidence of outdoor pollen exposure on various lung function and airway inflammation markers in community-based studies.

Methods: Four online databases were searched: Medline, Web of Science, CINAHL and Google Scholar. The search strategy included terms relating to both exposure and outcomes. Inclusion criteria were human-based studies published in English that were representative of the community. Additionally, we only considered cross-sectional or short-term longitudinal studies which investigated pollen exposure by levels or season. Study quality assessment was performed using the Newcastle-Ottawa scale. Meta-analysis was conducted using random-effects models.

Results: We included 27 of 6551 studies identified from the search. Qualitative synthesis indicated associations between pollen exposure and predominantly type-2 inflammation in both the upper and lower airways, but little evidence for lung function changes. People with ever asthma and/or seasonal allergic rhinitis (SAR) were at higher risk of such airway inflammation. Meta-analysis confirmed a positive relationship between pollen season, eosinophilia and eosinophil cationic protein (ECP) in people with ever SAR but the results between studies were highly variable. Heterogeneity was reduced after further subgrouping by age, and the forest plots indicated that eosinophilic airway inflammation to outdoor pollen exposure increased with age.

Conclusion: Among people with ever asthma and ever SAR, exposure to increased ambient pollen triggers type-2 upper and lower airway inflammation rather than a non-specific or innate inflammation. These findings can lead to the formulation of specific pollen immunotherapy for susceptible individuals. Future research should be directed towards investigating lagged associations and effect modifications using larger and more generalized populations.

Systematic Review Registration: CRD42020146981 (PROSPERO).
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http://dx.doi.org/10.1111/cea.13842DOI Listing
May 2021

Impact of air pollution on symptom severity during the birch, grass and ragweed pollen period in Vienna, Austria: Importance of O3 in 2010-2018.

Environ Pollut 2021 Feb 8;271:115790. Epub 2020 Dec 8.

School of Psychology and Public Health, La Trobe University, Melbourne, Australia. Electronic address:

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http://dx.doi.org/10.1016/j.envpol.2020.115790DOI Listing
February 2021

The contribution of group prenatal care to maternal psychological health outcomes: A systematic review.

Women Birth 2020 Dec 24. Epub 2020 Dec 24.

School of Psychology and Public Health, La Trobe University, Bundoora, 3086, Victoria, Australia. Electronic address:

Problem: Poor mental health remains a significant cause of morbidity for childbearing women globally.

Background: Group care has been shown to be effective in reducing select clinical outcomes, e.g., the rate of preterm birth, but less is known about the effect of Group Prenatal Care (GPC) on mental health outcomes of stress, depression and anxiety in pregnant women.

Aim: To conduct a systematic review of the current evidence of the effect of group pregnancy care on mental health and wellbeing outcomes (i.e., stress, depression and/or anxiety) in childbearing women.

Methods: A comprehensive search of published studies in Medline, PsychInfo, CINAHL, ProQuest databases, ClinicalTrials.gov and Google Scholar. Databases were systematically searched without publication period restriction until Feb 2020. Inclusion criteria were randomized controlled trials (including quasi-experimental) and observational studies comparing group care with standard pregnancy care. Included were studies published in English, whose primary outcome measures were stress, depression and/or anxiety.

Results: Nine studies met the inclusion criteria, five randomized controlled trials and four observational studies, involving 1585 women (39%) in GPC and 2456 women (61%) in standard (individual) pregnancy care. Although evidence is limited, where targeted education was integrated into the group pregnancy care model, significant reductions in depressive symptoms were observed. In addition, secondary analysis across several studies identified a subset of GPC women, i.e., higher risk for psychological symptoms, who reported a decrease in their depression, stress and anxiety symptoms, postpartum. Due to the diversity of group care structure and content and the lack of outcomes measures universally reported, a comprehensive meta-analysis could not be performed.

Conclusion: The evidence suggests improvements in some markers of psychological health outcomes with group pregnancy care. Future research should involve larger well-designed studies encompassing cross-population data using a validated scale that is comparable across diverse childbearing populations and clinical settings to better understand the impact of group pregnancy care.
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http://dx.doi.org/10.1016/j.wombi.2020.12.004DOI Listing
December 2020

Spatiotemporal characteristics of asthma emergency department presentations in diverse geographical and climatic regions, Queensland, Australia.

Emerg Med Australas 2021 Aug 23;33(4):623-630. Epub 2020 Nov 23.

School of Biomedical Sciences, Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.

Objective: Sudden acute episodes of asthma exacerbation are often treated by hospital EDs. It is hypothesised that determinants of acute asthma would differ across geographic regions. The objective of the present study was to detail seasonality, trends and spatiotemporal patterns of asthma ED presentations across Queensland (QLD), Australia, a state covering 1.8 million square kilometres, spanning multiple climates.

Methods: Six years of routinely collected data (2012 to 2017) from 28 major QLD public hospitals were extracted from Queensland Health's Emergency Data Collection. The dataset contained individual, episode-level asthma-like diagnoses of ED presentations. Seasonality and trends of acute asthma were assessed through multiplicative time-series analysis.

Results: The study consisted of 2192 days with a total of 65 012 asthma ED presentations in QLD. The 6-year average daily incidence rate was 270 asthma ED presentations per 100 000 population. The highest morbidity of asthma ED presentations occurred during the southern hemisphere winter months. Children showed a higher incidence rate compared to adults with males experiencing a higher incidence compared to females up until the age of 13, after which an inversion was observed persisting through adulthood. Seasonality of asthma ED presentations differed with latitude across QLD.

Conclusion: Asthma-related ED presentations exhibit spatiotemporal variation across QLD, which appears to be related to climate. Furthermore, aeroallergens and respiratory viruses may be responsible for asthma ED peaks outside the winter period. Socioeconomic status may influence asthma ED presentation rates between regions. This knowledge can guide ongoing management and assist public health policy response.
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http://dx.doi.org/10.1111/1742-6723.13687DOI Listing
August 2021

Trajectories of asthma and allergies from 7 years to 53 years and associations with lung function and extrapulmonary comorbidity profiles: a prospective cohort study.

Lancet Respir Med 2021 04 17;9(4):387-396. Epub 2020 Nov 17.

Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia. Electronic address:

Background: Longitudinal trajectories of asthma and allergies from childhood to adulthood might be differentially associated with lung function and chronic obstructive pulmonary disease (COPD), but associations with extrapulmonary comorbidities have not been well investigated. We aimed to assess these trajectories and examine their associations with lung function outcomes and profiles of comorbidities.

Methods: In this prospective cohort study, data for asthma and related allergic conditions (ie, eczema, hay fever, and food allergy) were prospectively collected from the Tasmanian Longitudinal Health Study for participants aged 7-53 years originally recruited in Tasmania, Australia. All surviving individuals in the database with contact details were invited in the most recent follow-up (mean age 53 years). There were no exclusion criteria. With use of latent class analysis, we identified longitudinal trajectories of asthma and allergic conditions from 7-53 years, and profiles of self-reported extrapulmonary conditions recorded at 53 years. The associations between asthma and allergy trajectories and morbidity profiles and lung function at 53 years were investigated with regression models.

Findings: Between Sept 3, 2012, and Nov 8, 2016, of 6128 individuals invited, 3609 (58·9%) individuals were enrolled. We identified five asthma and allergy trajectories: minimal and least asthma and allergies (n= 1767 [49·0%]); late-onset hay fever, no asthma (n=1065 [29·5%]); early-onset remitted asthma and allergies (n=236 [6·5%]); late-onset asthma and allergies (n=317 [8·8%]); and early-onset persistent asthma and allergies (n=224 [6·2%]); and four profiles of extrapulmonary morbidities: minimal or least disease (n=2206 [61·1%]); dominant mental health disorders (n=861 [23·9%]); dominant cardiovascular diseases or risks (n=424 [11·7%]); and multiple disorders (n=117 [3·2%]). The late-onset asthma and allergies trajectory was predominantly associated with the multiple disorders profile (relative risk ratio 3·3 [95% CI 1·9-5·9]), whereas the other asthma and allergy trajectories were associated only with the dominant mental health disorders profile. Both spirometrically defined and clinical COPD were most strongly associated with the early-onset persistent asthma and allergies trajectory (odds ratio [OR] 5·3 [95% CI 3·2-8·6]) and also with the late-onset asthma and allergies trajectory (OR 3·8 [2·4-6·1]).

Interpretation: Distinct longitudinal trajectories of asthma and allergic disease from childhood to 53 years are associated with different profiles of extrapulmonary comorbidities and varying risk of COPD. These findings can inform a personalised approach in clinical guidelines and management focusing on treatable traits. Comorbidity profiles are a new target for early identification and intervention.

Funding: National Health and Medical Research Council of Australia, EU's Horizon 2020, The University of Melbourne, Clifford Craig Medical Research Trust of Tasmania, The Victorian, Queensland & Tasmanian Asthma Foundations, The Royal Hobart Hospital, Helen MacPherson Smith Trust, and GlaxoSmithKline.
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http://dx.doi.org/10.1016/S2213-2600(20)30413-6DOI Listing
April 2021

Association of early life and acute pollen exposure with lung function and exhaled nitric oxide (FeNO). A prospective study up to adolescence in the GINIplus and LISA cohort.

Sci Total Environ 2021 Apr 20;763:143006. Epub 2020 Oct 20.

Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne, Australia; Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia. Electronic address:

Background: Pollen exposure has both acute and chronic detrimental effects on allergic asthma, but little is known about its wider effects on respiratory health. This is increasingly important knowledge as ambient pollen levels are changing with the changing global climate.

Objective: To assess associations of pollen exposure with lung function and fractional exhaled nitric oxide (FeNO) at age 15 in two prospective German birth cohorts, GINIplus and LISA.

Methods: Background city-specific pollen exposure was measured in infancy (during the first three months of life), and contemporary (on the day of and 7 days prior to lung function measurement). Greenness levels within circular buffers (100-3000 m) around the birth and 15-year home addresses were calculated using the satellite-derived Normalized Difference Vegetation Index. Regression models were used to assess the associations of grass and birch pollen with lung function and FeNO, and the modifying effects of residential greenness were explored.

Results: Cumulative early life exposure to grass pollen was associated with reduced lung function in adolescence (FEV: -4.9 mL 95%CI: -9.2, -0.6 and FVC: -5.2 mL 95%CI: -9.8, -0.5 per doubling of pollen count). Acute grass pollen exposure was associated with increased airway inflammation in all children, with higher FeNO increases in children living in green areas. In contrast acute birch pollen exposure was associated with reduced lung function only in children sensitised to birch allergens.

Conclusion: This study provides suggestive evidence that early pollen exposure has a negative effect on later lung function, which is in turn influenced by acute pollen exposures.
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http://dx.doi.org/10.1016/j.scitotenv.2020.143006DOI Listing
April 2021

Sufficient vitamin D status positively modified ventilatory function in asthmatic children following a Mediterranean diet enriched with fatty fish intervention study.

Nutr Res 2020 10 16;82:99-109. Epub 2020 Aug 16.

La Trobe University, School of Psychology & Public Health, Department of Public Health, Melbourne, Australia. Electronic address:

Asthma in children is the most prevalent allergic disease worldwide that has become a major public health priority. The objective of this study was to examine the relationship between baseline serum vitamin D status, spirometry, and fractional exhaled nitric oxide levels (FeNO) in 64 Greek children with 'mild asthma' aged 5 to 12 years (51.6% male) in a dietary intervention study. We hypothesized that baseline serum vitamin D levels modify the beneficial response of fatty fish intake on pulmonary function in asthmatic children following a Mediterranean diet. The intervention group consumed 2 fatty fish meals/week (≥150 g cooked filleted fish/meal) as part of the Mediterranean diet for six months, and the control group consumed their usual diet. Baseline serum 25(OH)D was determined using enzyme-linked immunoassay and defined as sufficient levels of 25(OH)D ≥25 ng/mL. Only 36% of children were graded as sufficient in 25(OH)D levels on entry into the study with a higher proportion of girls insufficient than boys (61% vs 39% respectively). Participants with sufficient levels of serum 25(OH)D at baseline, consuming the intervention diet increased FEV/FVC by 4.89 units (β = 4.89; 95%CI: 1.19-8.61; p = 0.013) and FEF by 12.83 units (β = 12.83; 95%CI: 4.27-21.40; p = 0.006) compared to controls. No significant differences in pulmonary function or FeNO were observed for those with insufficient levels of 25(OH) D in the intervention or control groups. In conclusion, sufficient serum vitamin D levels enhanced ventilatory function in response to a dietary intervention in asthmatic children.
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http://dx.doi.org/10.1016/j.nutres.2020.08.004DOI Listing
October 2020

Current methods inadequate in assessing the association between junk food intake and metabolic syndrome in children and adolescents: letter to editor.

Eat Weight Disord 2021 May 20;26(4):1277-1278. Epub 2020 Sep 20.

School of Psychology and Public Health, La Trobe University, Melbourne, VIC, 3086, Australia.

It is of great interest to understand how diet may influence the onset and progression of metabolic syndrome (MetS) in pediatric age groups, as MetS in childhood and adolescence is associated with an increased risk of cardiovascular disease and type-2 diabetes in adulthood. Recently, Azemati and colleagues (2020) reported no association between junk food intake and MetS in Iranian children and adolescents aged 7-18 years; however, we have identified some methodological limitations in this study, which are important to consider when examining MetS risk, especially in samples of this age. In response, we have developed a letter to the editor detailing the issues associated with defining MetS in pediatric age groups and how pubertal maturation and visceral adipose tissue are important variables to assess.
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http://dx.doi.org/10.1007/s40519-020-01011-5DOI Listing
May 2021

Is short-term exposure to grass pollen adversely associated with lung function and airway inflammation in the community?

Allergy 2021 04 15;76(4):1136-1146. Epub 2020 Sep 15.

Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Vic., Australia.

Background: The association between grass pollen exposure and early markers of asthma exacerbations such as lung function changes and increase in airway inflammation is limited. We investigated the associations between short-term grass pollen exposure and lung function and airway inflammation in a community-based sample, and whether any such associations were modified by current asthma, current hay fever, pollen sensitization, age, and other environmental factors.

Methods: Cross-sectional and short-term analyses of data from the Melbourne Atopy Cohort Study (MACS) participants (n = 936). Lung function was assessed using spirometry. Airway inflammation was assessed by fractional exhaled nitric oxide (FeNO) and exhaled breath condensate pH and nitrogen oxides (NOx). Daily pollen counts were collected using a volumetric spore trap. The associations were examined by linear regression.

Results: Higher ambient levels of grass pollen 2 days before (lag 2) were associated with lower mid-forced expiratory flow (FEF ) and FEV /FVC ratio (Coef. [95% CI] = -119 [-226, -11] mL/s and -1.0 [-3.0, -0.03] %, respectively) and also 3 days before (lag 3). Increased levels of grass pollen a day before (lag 1) were associated with increased FeNO (4.35 [-0.1, 8.7] ppb) and also at lag 2. Adverse associations between pollen and multiple outcomes were greater in adults with current asthma, hay fever, and pollen sensitization.

Conclusion: Grass pollen exposure was associated with eosinophilic airway inflammation 1-2 days after exposure and airway obstruction 2-3 days after exposure. Adults and individuals with asthma, hay fever, and pollen sensitization may be at higher risk.
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http://dx.doi.org/10.1111/all.14566DOI Listing
April 2021

Sugar-sweetened beverage consumption is associated with visceral fat in children.

Br J Nutr 2020 Aug 19:1-9. Epub 2020 Aug 19.

Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne, VIC3086, Australia.

Sugar-sweetened beverage (SSB) consumption has been associated with visceral fat partitioning in adults; however, the underlying mechanisms in childhood remain unclear and warrant exploration. This cross-sectional study aimed to investigate the association between SSB consumption and body fat in children aged 9-13 years and the potential modifying effect of children's sex and serum cortisol levels. A sample of 2665 Greek schoolchildren participated in the 'Healthy Growth Study', and anthropometric, body composition, dietary intake and serum cortisol data were assessed. SSB consumption was defined as low (<1 serving/d), medium (1-2 servings/d) or high (>2 servings/d). We used linear regression models to assess the association between SSB consumption and measures of adiposity and to assess effect modification; models were stratified by sex and tertiles of morning serum cortisol. A significant positive association was observed between high SSB consumption and visceral adipose tissue (VAT) (β = 1·4, 95 % CI 0·4, 2·3, P = 0·01) but not BMI or BMI z-score. When stratified by sex, the association was observed in boys (β = 1·8, 95 % CI 0·3, 3·4, P = 0·02) but not in girls. When stratified by cortisol levels, SSB consumption was associated with VAT in children with cortisol levels in the lowest tertile (β = 2·8, 95 % CI 1·0, 4·6, P < 0·01). These results indicate that increased SSB consumption is associated with visceral adiposity in schoolchildren and this association may be modified by sex and morning serum cortisol. To prevent VAT accumulation and concomitant disease risk, dietary interventions should target SSB consumption during childhood.
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http://dx.doi.org/10.1017/S0007114520003256DOI Listing
August 2020

Associations between grass pollen exposures and in early life with food allergy in 12-month-old infants.

Int J Environ Health Res 2020 Jul 17:1-11. Epub 2020 Jul 17.

School of Psychology and Public Health, La Trobe University, Melbourne, Australia.

Birth during pollen seasons may influence food allergy risk but no study has assessed pollen exposure. Using the HealthNuts population-based cohort of 5276 infants, we assessed grass pollen exposures, and up to the first 6 months of life, on hen's egg, sesame and peanut allergy outcomes at 12 months. Cumulative pollen exposure in the first 7 days of life increased risk of peanut sensitization aMOR (adjusted multinomial odds ratio) = 1.21 (95% CI: 1.01-1.44). Exposure between first 4-6 months of life increased risk of hen's egg aMOR = 1.02 (95% CI: 1.004-1.04) and sensitization to all foods aMOR = 1.02 (95% CI: 1.003-1.04). Grass pollen exposure was associated with food challenge diagnosed food allergy, but only among infants with a maternal history of food allergy. Exposure to grass pollen in the period and infancy may be important but more studies are needed to replicate these findings.
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http://dx.doi.org/10.1080/09603123.2020.1793920DOI Listing
July 2020

Tree pollen exposure is associated with reduced lung function in children.

Clin Exp Allergy 2020 10 27;50(10):1176-1183. Epub 2020 Jul 27.

Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne, Vic., Australia.

Background: Allergic disease is a recognized global epidemic and a significant cause of ill health and poor quality of life. The prevalence of pollen allergy is high throughout the world, and pollen exposure itself plays a role in emergency department presentations and hospitalizations for asthma. Lung function and airway inflammation are important measures of asthma activity and control.

Objective: To examine associations between exposure to multiple pollen types and lung function and markers of airway inflammation at 8 and 14 years of age, and to explore potential modification by residential greenness.

Methods: A cohort of high-risk children living in Sydney, Australia had spirometry and fractional exhaled nitric oxide (FeNO) measured at 8 and 14 years of age. Ambient pollen concentration on the day of lung function measurement and up to three days prior was used as the exposure measure. Residential greenness was derived from satellite imagery. We modelled the association between six pollen types and lung function and FeNO. We also assessed modifying effects of residential greenness.

Results: Casuarina, cypress and Pinus pollen in the air the day before measurement and 3 days prior respectively, were associated with reduced lung function in 8-year-olds. The pollen exposures were associated with decreases in FEV and FVC; however, the FEV /FVC ratio was not affected. Effect modification by greenness was not observed due to loss of power.

Conclusions & Clinical Relevance: Airborne tree pollen of cypress, Casuarina and Pinus and not grass in some regions may be detrimental to childhood lung function.
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http://dx.doi.org/10.1111/cea.13711DOI Listing
October 2020

Serum cytokine concentrations and asthma persistence to middle age.

Allergy 2020 11 9;75(11):2985-2988. Epub 2020 Jul 9.

Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Vic., Australia.

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http://dx.doi.org/10.1111/all.14448DOI Listing
November 2020

Is self-reported history of eczema and hay fever a valid measure of atopy in those who report current asthma?

Allergy 2020 11 7;75(11):2981-2984. Epub 2020 Aug 7.

Allergy and Lung Health Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Vic., Australia.

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http://dx.doi.org/10.1111/all.14440DOI Listing
November 2020

Thunderstorm Asthma Epidemic-A Systematic Review of the General Practice Perspective.

Int J Environ Res Public Health 2020 05 27;17(11). Epub 2020 May 27.

Department of Public Health, School of Psychology and Public Health, La Trobe University, Bundoora, VIC 3086, Australia.

Thunderstorm asthma (TA) epidemics have been recognized globally as a rare phenomenon, producing a rapid surge of acute asthma presentations leading to an increased demand on emergency medical services and healthcare resources. General practitioners (GPs) are well placed in the community to contribute to healthcare during TA epidemics and similar disaster events. The aim of this review was to synthesize current evidence of the experiences of GPs during TA epidemics and similar surge events. A comprehensive systematic search of eleven electronic databases, including ancestry searching for peer-reviewed studies and grey literature published in English was conducted. Quantitative and qualitative study designs were included, and a quality assessment conducted. Of the 125 records identified, 16 were included for synthesis. During TA epidemics and surge events, GPs experience an increased demand for services, yet it is not known if general practice clinics experience resource limitations from this patient surge. While GPs express a willingness to help, few structures are in place to liaise, support and provide information to GPs during surge events. Following most surge/disaster events, no GP data is collected so it is not known how to improve coordination and communication between general practice services and emergency services. GPs have well-functioning adaptive management systems, and resources of space, supplies and staff thus the ability to increase surge capacity of their clinics.
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http://dx.doi.org/10.3390/ijerph17113796DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7312025PMC
May 2020

Ambient pollen concentrations and asthma hospitalization in children and adolescents: a systematic review and meta-analysis.

J Asthma 2020 Jun 1:1-14. Epub 2020 Jun 1.

School of Psychology and Public Health, La Trobe University, Melbourne, Australia.

We aimed to conduct a systematic review examining the association between outdoor pollen and childhood asthma hospitalizations. A systematic search of articles in MEDLINE, EMBASE, CINAHL, ProQuest Central, Web of Science and Google Scholar published to 18 July 2019. Studies that presented data on pollen exposure and childhood asthma hospitalization were included and evaluated for potential risk of bias by two independent authors. Random effects meta-analysis was performed where possible. A total of 1048 records were identified, and twelve studies included in the review. The synthesis suggested possible associations between outdoor pollen, especially for grass and birch and childhood asthma hospitalization. However, the results varied widely across geographical areas and settings for other pollen taxa. The meta-analysis of the case-crossover studies showed a positive association between grass and childhood asthma hospitalization, an increase in 10 grass pollen grains/m was associated with a 3% increase in childhood asthma admission (OR = 1.03; 95%CI:1.01, 1.04), but the pooled estimate was not significant for timeseries studies. The meta-analysis of the timeseries studies for birch pollen showed an increase in 10 pollen grains/m being significantly associated with a Mean Percentage Change (MPC) in childhood asthma admissions (MPC= 0.85; 95%CI:0.40, 1.30). Globally, grass and birch pollen are important triggers of childhood asthma hospitalization, but the association could not be ascertained for other pollen taxa. Pollen is a major environmental trigger of asthma exacerbations and more focus on early interventions to reduce this burden needs to be considered.
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http://dx.doi.org/10.1080/02770903.2020.1771726DOI Listing
June 2020

Water, sanitation and hygiene practices associated with improved height-for-age, weight-for-height and weight-for-age z-scores among under-five children in Nepal.

BMC Pediatr 2020 03 23;20(1):134. Epub 2020 Mar 23.

The Department of Mathematics and Statistics, La Trobe University, Melbourne, Australia.

Background: Evidence of the influence of water, sanitation and hygiene (WASH) behaviors on childhood nutritional status is inconsistent. Few studies have examined their interactive effects. This study aimed to examine associations and interactions between WASH variables and preschool child undernutrition.

Methods: Data from a nationally representative sample of 2352 children assessed during the 2016 Nepal Demographic and Health Survey were analyzed by multi-variable linear regression to understand the association between height-for-age (HAZ), weight-for-height (WHZ) and weight-for-age (WAZ) z-scores and WASH variables. Interactions between WASH variables, sex and area of residence on childhood nutritional status were also examined.

Results: The mean z-score [standard deviation] for children's WAZ, HAZ and WHZ scores were - 1.33 [1.1], - 1.52 [1.3] and - 0.65 [1.1], respectively. A unit increase in cluster sanitation coverage was associated with an increase of 0.30 (95%CI: 0.12 to 0.48) for WAZ and 0.28 (95%CI: 0.001 to 0.56) for HAZ scores. Household water purification practice was associated with an increase of 0.24 (95%CI: 0.07 to 0.41) in WHZ score. Handwashing practice with water and soap was associated with an increase of 0.15 (95%CI: 0.04 to 0.25) in WAZ and 0.13 (95%CI: 0.01 to 0.24) in WHZ scores. The effect of water purification practice was higher for rural areas compared to urban settings for HAZ scores (p-value for interaction = 0.02).

Conclusions: Consistent with findings from other countries in the South Asian region, findings of this study highlight the potential importance of good WASH practices, and therefore the potential of WASH interventions, to contribute to improved nutritional status in rural Nepal.
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http://dx.doi.org/10.1186/s12887-020-2010-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7092611PMC
March 2020

Early life acetaminophen exposure, glutathione S-transferase genes, and development of adolescent asthma in a high-risk birth cohort.

J Allergy Clin Immunol 2020 11 11;146(5):1035-1044.e12. Epub 2020 Apr 11.

Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, the University of Melbourne, Melbourne, Australia.

Background: Although the impact of early life acetaminophen on asthma risk is still not clear, potential interactions with glutathione S-transferase (GST) genes due to reduced antioxidant function in particular polymorphisms, and possible impact on lung function, have never been investigated in adolescents.

Objective: We aimed to investigate associations between early life acetaminophen use and adolescent asthma and lung function and to assess potential interactions by GST polymorphisms.

Methods: Acetaminophen use was recorded 18 times up to age 2 years (n = 575 [92.7%]). Participants were genotyped for GST polymorphisms (GSTM1/T1/P1) (n = 429 [69.2%]). Asthma and lung function were measured at 12 (n = 365 [58.9%]) and 18 years (n = 413 [66.6%]). Regression models assessed associations and interactions.

Results: Doubling of days of acetaminophen use was associated with reduced prebronchodilator FEV/forced vital capacity (β coefficient, -0.10; 95% CI, -0.19 to -0.01) and midexpiratory flow (-0.09; 95% CI, -0.18 to 0) at 18 years, but this association was not found when restricted for nonrespiratory reasons, suggesting confounding by indication. However, in children with GSTM1 null and GSTT1 present, increasing acetaminophen use for nonrespiratory reasons was associated with reduced FEV and midexpiratory flow at 18 years (interaction between GSTM1/T1 and acetaminophen P < .05). Increased acetaminophen use was associated with asthma at 18 years for children with GSTP1 Ile/Ile (odds ratio, 1.66; 95% CI, 1.07 to 2.57), but not other GSTP1 genotypes.

Conclusions: These novel findings need to be investigated for consistency in other studies but suggest that children carrying risk genotypes may be susceptible to respiratory consequences from acetaminophen use.
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http://dx.doi.org/10.1016/j.jaci.2020.03.027DOI Listing
November 2020

Grass pollen as a trigger of emergency department presentations and hospital admissions for respiratory conditions in the subtropics: A systematic review.

Environ Res 2020 03 8;182:109125. Epub 2020 Jan 8.

School of Biomedical Sciences, Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia; Office of Research, Metro North Hospital and Health Services,Herston, Queensland, Australia.

Introduction: It is unknown if high concentration of airborne grass pollen, where subtropical grasses (Chloridoideae and Panicoideae) dominate, is a risk factor for respiratory health. Here we systematically reviewed the association between airborne grass pollen exposure and asthma emergency department (ED) presentations and hospital admissions in subtropical climates.

Objectives: A systematic review was performed to identify and summarise studies that reported on respiratory health (asthma ED presentations and hospital admissions) and airborne grass pollen exposure in subtropical climates.

Methods: Searches were conducted in: MEDLINE, Web of Science, Scopus, CINAHL (EBSCO), Embase and Google Scholar databases (1966-2019). Risk of bias was assessed using a validated quality assessment tool. A meta-analysis was planned, however due to the heterogeneity in study design it was determined inappropriate and instead a narrative synthesis was undertaken.

Results: Nineteen studies were identified for inclusion, with a total of 598,931 asthma ED presentation participants and 36,504 asthma hospital admission participants in six countries (Australia, India, Israel, Italy, Spain, USA). The narrative synthesis found airborne grass pollen appears to have a small and inconsistent increase on asthma ED presentations (judged as: probably little effect n = 5, may have little effect n = 4, no effect n = 2 and uncertain if there is an effect n = 4) and hospital admissions (judged as: probably increase slightly n = 2 probably little effect n = 1, may have a little effect n = 1, no effect n = 3 and we are uncertain if there is an effect n = 4) in the subtropics. Furthermore, the reported effect sizes were small and its clinical relevance may be difficult to discern.

Conclusion: Exposure to airborne grass pollen appears to have a small and inconsistent increase on asthma ED presentations and hospital admissions in the subtropics. These findings are comparable to reported observations from studies undertaken in temperate regions.
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http://dx.doi.org/10.1016/j.envres.2020.109125DOI Listing
March 2020

Thunderstorm asthma epidemic - management challenges experienced by general practice clinics.

J Asthma 2021 Apr 3;58(4):423-429. Epub 2020 Jan 3.

School of Psychology and Public Health, La Trobe University, Melbourne, Australia.

Objectives: To understand the challenges faced by general practice (GP) services in terms of personnel, materials, secondary support services, and discharge and communication obstacles during the thunderstorm asthma (TA) epidemic in 2016.

Methods: Qualitative study using semi-structured interviews and focus groups between September and October 2017. Participants were general practitioners (GPs), practice nurses, and administrative staff working on the TA epidemic days in the northern region of Melbourne, Australia.

Results: 18 participants contributed to the study from six clinic sites. Both daytime and evening clinics experienced a surge in respiratory patient presentations. After-hours clinics were inundated with asthma patients during the night of the thunderstorm. Consistent themes emerged about the challenges encountered by participants the most significant being limitation of medication, equipment, space, and personnel. The extraordinary influx of patients necessitated participants innovate solutions including recycling equipment, procuring medications from hospitals and community pharmacies, triage, altering management strategies and extending clinic hours. Participants were limited by the paucity of information from local services during the TA epidemic.

Conclusion: This study supports the view that GP services made a substantial contribution to the emergency response on the evening of the TA epidemic that occurred in Melbourne in 2016. Demands on resources were considerable during and after the epidemic yet GP staff showed great resilience increasing clinic surge capacity. Our findings indicate significant barriers at an organizational level including resource limitations, inadequate operational information, and the absence of timely communication channels that impaired the response of GP services during a TA event.
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http://dx.doi.org/10.1080/02770903.2019.1708097DOI Listing
April 2021

Lifetime Risk Factors for Pre- and Post-Bronchodilator Lung Function Decline. A Population-based Study.

Ann Am Thorac Soc 2020 03;17(3):302-312

Allergy and Lung Health Unit, The University of Melbourne, Melbourne, Victoria, Australia.

Interactions between early life and adult insults on lung function decline are not well understood, with most studies investigating prebronchodilator (pre-BD) FEV decline. To investigate relationships between adult risk factors and pre- and post-BD lung function decline and their potential effect modification by early life and genetic factors. Multiple regression was used to examine associations between adult exposures (asthma, smoking, occupational exposures, traffic pollution, and obesity) and decline in both pre- and post-BD spirometry (forced expiratory volume in 1 s [FEV], forced vital capacity [FVC], and FEV/FVC) between ages 45 and 53 years in the Tasmanian Longitudinal Health Study ( = 857). Effect modification of these relationships by childhood respiratory risk factors, including low childhood lung function and GST (glutathione S-transferase) gene polymorphisms, was investigated. Baseline asthma, smoking, occupational exposure to vapors/gases/dusts/fumes, and living close to traffic were associated with accelerated decline in both pre- and post-BD FEV. These factors were also associated with FEV/FVC decline. Occupational exposure to aromatic solvents was associated with pre-BD but not post-BD FEV decline. Maternal smoking accentuated the effect of personal smoking on pre- and post-BD FEV decline. Lower childhood lung function and having the GSTM1 null allele accentuated the effect of occupational exposure to vapors/gases/dusts/fumes and personal smoking on post-BD FEV decline. Incident obesity was associated with accelerated decline in FEV and more pronounced in FVC. This study provides new evidence for accentuation of individual susceptibility to adult risk factors by low childhood lung function, GSTM1 genotype, and maternal smoking.
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http://dx.doi.org/10.1513/AnnalsATS.201904-329OCDOI Listing
March 2020

A systematic review of the role of grass pollen and fungi in thunderstorm asthma.

Environ Res 2020 02 16;181:108911. Epub 2019 Nov 16.

School of Psychology and Public Health, La Trobe University, Bundoora, 3086, Victoria, Australia. Electronic address:

Background: Thunderstorm asthma is defined as epidemics of asthma occurring shortly after a thunderstorm. While grass pollen has been implicated in thunderstorm asthma events, little is known about the role of fungi and studies have not been synthesised.

Objective: This systematic review aims to evaluate whether grass pollen is necessary in thunderstorm asthma events and whether fungi also play a part in these associations.

Methods: We conducted a systematic search using six electronic databases (i.e. CINAHL, Medline (Ovid), Web of Science, ProQuest Central, EMBASE and Google Scholar) and checked reference lists. The search terms used were pollen AND thunderstorm* AND asthma. The inclusion criteria were studies published in English with original human data relating to outdoor pollen and thunderstorm asthma.

Results: Twenty of 2198 studies were eligible. Reported findings differed due to variation in methodological approaches and a meta-analysis was not possible. Nonetheless, of the 20 studies included, 15 demonstrated some relationship with nine demonstrating lagged effects up to four days for increasing grass pollen counts associated with increased risk of thunderstorm asthma. Of the 10 studies that examined fungi, nine demonstrated a positive relationship with thunderstorm asthma. The fungal taxa involved varied, depending on whether measurements were recorded before, during or after the thunderstorm. Nevertheless, none of the studies considered fungi as a potential effect modifier for the pollen-thunderstorm asthma association.

Conclusion: We found evidence to suggest that grass pollen was a necessary factor for thunderstorm asthma but there are other as yet unrecognised environmental factors that may also be important. Further research is required to examine the role of fungi and other environmental factors such as air quality as potential effect modifiers of the association.
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http://dx.doi.org/10.1016/j.envres.2019.108911DOI Listing
February 2020

Risk factors for foot ulceration in adults with end-stage renal disease on dialysis: a prospective observational cohort study.

BMC Nephrol 2019 11 21;20(1):423. Epub 2019 Nov 21.

Discipline of Podiatry, School of Allied Health, Health Services and Sport, La Trobe University, Melbourne, Victoria, 3086, Australia.

Background: Dialysis patients experience high rates of foot ulceration. Although risk factors for ulceration have been extensively studied in patients with diabetes, there is limited high-quality, longitudinal evidence in the dialysis population. Therefore, this study investigated risk factors for foot ulceration in a stable dialysis cohort.

Methods: We prospectively collected clinical, demographic, health status, and foot examination information on 450 adults with end-stage renal disease from satellite and home-therapy dialysis units in Melbourne, Australia over 12 months. The primary outcome was foot ulceration. Cox proportional hazard modelling and multinomial regression were used to investigate risk factors.

Results: Among 450 dialysis patients (mean age, 67.5 years; 64.7% male; 94% hemodialysis; 50.2% diabetes), new cases of foot ulceration were identified in 81 (18%) participants. Overall, risk factors for foot ulceration were neuropathy (HR 3.02; 95% CI 1.48 to 6.15) and previous ulceration (HR 2.86; CI 1.53 to 5.34). In those without history of ulceration, nail pathology (RR 3.85; CI 1.08 to 13.75) and neuropathy (RR 2.66; CI 1.04 to 6.82) were risk factors. In those with history of ulceration, neuropathy (RR 11.23; CI 3.16 to 39.87), peripheral arterial disease (RR 7.15; CI 2.24 to 22.82) and cerebrovascular disease (RR 2.08; CI 1.04 to 4.16) were risk factors. There were 12 (2.7%) new amputations, 96 (21.3%) infections, 24 (5.3%) revascularizations, 42 (9.3%) foot-related hospitalizations, and 52 (11.6%) deaths.

Conclusions: Neuropathy and previous ulceration are major risk factors for foot ulceration in dialysis patients. Risk factors differ between those with and without prior ulceration. The risk factors identified will help to reduce the incidence of ulceration and its associated complications.
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http://dx.doi.org/10.1186/s12882-019-1594-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868750PMC
November 2019
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