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Letters / Ann Allergy Asthma Immunol 112 (2014) 71e82
Clinical assessment of allergen immunotherapy with differing doses of horse extract Allergen immunotherapy is an effective form of therapy for allergic rhinitis because of a wide variety of allergens, including animals. Exposure to horses through commercial and leisure activities is increasing, and people experience respiratory symptoms, including allergic rhinitis, with horse exposure.1 The effective doses have been described for immunotherapy with cat and dog extract.2,3 Five horse allergens have been described, including Equ c 1, Equ c 2 (lipocalins), Equ c 3 (serum albumin), Equ c 4, and Equ c 5 (unknown function).4 However, immunotherapy with horse extract has been less extensively studied. One previous study from Spain found clinical efficacy with one standardized extract of horse dander.5 However, there are few clinical data regarding efficacy with differing doses of horse extract, and it is unknown which dose is most effective. We report a clinical observation regarding our experience in patients with differing doses of immunotherapy with horse extract. Eight patients, ranging in age from 9 to 57 years, with allergic rhinitis symptoms on exposure to horse and positive skin prick test results to horse dander were treated with horse extract (1:20 wt/vol produced by Greer Laboratories). The doses ranged from 0.2 to 1.0 mL of horse extract (of a 5-mL immunotherapy vial). Subcutaneous immunotherapy was administered on a weekly basis starting with a 1:10,000 dilution to a maintenance dose of 0.5 mL (of a 5-mL vial) of a 1:10 dilution. Three patients were treated with 0.3 mL of horse extract, 3 patients were treated with 0.25 mL of horse extract, 1 patient was treated with 0.2 mL of horse extract, and 1 patient was treated with 1.0 mL of horse extract (Table 1). Total nasal symptom scores (TNSSs) to horse exposure were recorded before initiation of immunotherapy and on reaching maintenance dose (Table 1). Nasal congestion, sneezing, rhinorrhea, and nasal itch were scored from 0 to 3 (0 indicating no symptoms; 1, mild symptoms; 2, moderate symptoms; and 3, severe symptoms), with the maximum score being 12.6 The mean TNSS score of all the treated patients before initiation of therapy was 8.5, and the mean TNSS score after arrival at the maintenance dose was 2.25. Statistical analysis of the data was performed by use of StatPac software (StatPac Inc, Bloomington, Minnesota). A matchedpairs t test between means was calculated, showing a significant difference in means before and after treatment (P ¼ .004). No adverse events were caused by the immunotherapy. Our clinical observation shows improvement with horse allergen extract immunotherapy.
Disclosures: The authors have nothing to disclose.
Table 1 Effect of differing doses of horse allergen immunotherapy Patient Horse extract dose TNSS before horse TNSS after horse age, y/sex (in a 5-mL vial), mL extract immunotherapy extract immunotherapy 44/F 35/F 45/F 15/F 9/M 57/F 9/F 46/M
0.2 0.25 0.25 0.25 0.3 0.3 0.3 1.0
12 4 8 4 12 8 12 8
4 0 5 0 1 8 0 0
Abbreviation: TNSS, Total Nasal Symptom Score.
In the future, additional larger studies may be performed to assess which exact dose is most clinically effective and to assess titrated skin prick responses, horse dander specific IgE and IgG4 levels, and analysis of CD4þ/CD25þ suppressor T cells in patients undergoing immunotherapy with horse allergen extract. Anil Nanda, MD*,y Anita N. Wasan, MDz *Asthma and Allergy Center Lewisville, Texas y Division of Allergy and Immunology University of Texas Southwestern Medical Center Dallas, Texas z Allergy and Asthma Center Lansdowne, Virginia [email protected] References [1] Mazan MR, Svatek J, Maranda L, et al. Questionnaire assessment of airway disease symptoms in equine barn personnel. Occup Med. 2009;59:220e225. [2] Nanda A, O’Connor M, Anand M, et al. Dose dependence and time course of the immunologic response to administration of standardized cat allergen extract. J Allergy Clin Immunol. 2004;114:1339e1344. [3] Lent A, Harbeck R, Strand M, et al. Immunologic response to administration of standardized dog allergen extract at differing doses. J Allergy Clin Immunol. 2006;118:1249e1256. [4] Weber RW. On the Cover: horse dander. Ann Allergy Asthma Immunol. 2010;105:A12. [5] Fernandez-Tavora L, Rico P, Martin S. Clinical experience with specific immunotherapy to horse dander. J Investig Allergol Clin Immunol. 2002;12:29e33. [6] Nicholson G, Kariyawasam H, Tan A, et al. The effects of an anti-IL-13 mAb on cytokine levels and nasal symptoms following nasal allergen challenge. J Allergy Clin Immunol. 2011;128:800e807.
Allergy products traded on eBay, 2007-2012 Use of the Internet has increased significantly since 2000, and it is increasingly being used for health information and health care delivery.1 The Internet also provides online marketplaces that facilitate purchase and trade of health care products, including some drugs that were previously only available by prescription.2,3 Allergic conditions are common, and there is a trend toward self-diagnosis and treatment. Understandably, most patients with allergic conditions wish to improve their quality of life and engage in normal recreational and occupational activities. Often they modify their behavior Disclosures: Authors have nothing to disclose.
or purchase over-the-counter medicines or alternative therapies, without necessarily feeling the need to seek medical advice.4 Many allergy-related products are available online. eBay.co.uk was launched in 1999 and is the United Kingdom’s largest and most visited online retail website, with more than 14 million active users who sell and buy through auctions every month.5 We examined the type and range of allergy-related products available on eBay.co.uk between January 2007 and August 2012 and reviewed the implications for people with allergy. The website (www.ebay.co.uk) was searched using the term allergy during 5 separate periods: January
Letters / Ann Allergy Asthma Immunol 112 (2014) 71e82
77
Table 1 Number of items and relative increase in allergy products advertised on eBay.co.uk 2007d2012 Categories of Products
January 2007
June 2009
July 2012
January 2007 (%)
June 2009 (%)
July 2012 (%)
Products for the home Hypoallergenic items Books Pharmaceuticals Alternative therapies Other Overall
185 10 14 12 10 16 247
612 216 362 101 88 106 1485
969 1238 1208 298 252 366 4331
75 4 6 5 4 6 100
41 15 24 7 6 7 100
22 29 28 7 6 8 100
2007,6 June 2007, June 2009, January to February 2012, and July to August 2012. In each period we collected data at 10 AM on 5 days during 2 consecutive weeks. In July to August 2012, data were collected at 4 additional times of day to track within-day changes of individual categories and subcategories. Seven main groups of products were identified: home products, books, hypoallergenic items, pharmaceuticals, alternative therapies, diagnostic tests, and other. Each of these groups was then further subcategorized. Home products included items intended to reduce allergens within the home, such as vacuum cleaners and their associated parts, cleaning materials, bedding, and pet supplies. Books were subdivided into cookery books, patient information materials, information books for children, and a combined subcategory of medical textbooks and clinical research books. Hypoallergenic items included jewelry, toiletries, and cosmetics. Alternative therapies included light therapy, healing crystals, skin balms, herbal tablets, vitamins, and supplements. Diagnostic tests ranged from conventional allergen IgE tests for grass pollen to alternative tests using hair or fingertip blood samples. Other products included medical alert bracelets, tickets for an allergy show, a trading card game, and supermarket club card points. Between 2007 and 2012, the proportion of UK Internet users selling any type of goods or services online via auction doubled (from 13.5% to 27%),7 whereas the daily mean number of allergy-related items sold on eBay.co.uk increased from 247 to 4,295. In 2007, more than 75% of all items were products for the home, but by 2012 this had decreased to 22%. Hypoallergenic products increased from 4% in 2007 to 29% in 2012, whereas books increased from 6% to 28% (Table 1). Pharmaceuticals, allergy tests, alternative therapies, and others all increased in absolute numbers but remained stable as a proportion of the total. The most frequently traded category was books, with a mean daily turnover greater than 3% in 2012. Within the home products category, bedding for adults and infants increased from 49% in 2007 to 71% in 2012. Among hypoallergenic products, jewelry increased from 8% in 2009 to 20% in 2012. The proportion of clinical textbooks has increased markedly, to 22% of all books on offer. During the last 5 years, a wide range of allergy products have been auctioned and traded daily on eBay. Most of these products aim to reduce exposure to allergens (either home products or hypoallergenic items, such as jewelry). Across the board there is a trend for more products being traded for allergic conditions in children. Although the overall number within each category has increased, there has been relative growth in hypoallergenic items and booksdnot just clinical textbooks but also books providing cookery and patient information, suggesting that people are trying to manage their allergies and educate themselves about their condition. As with other health care areas, accessing products for allergy online could benefit consumers and patients, but there are concerns about the safety and efficacy of online products, particularly about the safe and appropriate use of nonprescription medicines purchased online. With increasing choice comes increased uncertainty for consumers and patients. Not all products offered
are trustworthy, and the casual customer may find it difficult to distinguish what is useful for them and what is inappropriate. In part the increased number of auctions reflects the increasing commercialization of eBay, with major manufacturers and retailers using this route to promote their products. Together with more stringent regulations and higher fees for sellers, this trend has reduced the visibility of individual advertisers and, paradoxically, has narrowed the range of available products even though the volume of advertised products increases. Although our study focused on the United Kingdom, eBay is a global phenomenon, with 12.5 million auctions daily across 28 markets. We conducted a parallel analysis of eBay.com in July to August 2012. Although there were slightly more items on offer (mean, 5,294 items), the only significant difference was the relative higher proportion of over-the-counter medicines (18%) and alternative therapies (12%) traded on eBay.com compared with eBay.co.uk. A total of 14% of advertised items were products for the home and 15% were books. In conclusion, the number of allergy-related products available on eBay.co.uk increased 17-fold between 2007 and 2012. This is probably mirrored in other Internet marketplaces. The availability of these items may help people with allergies manage their conditions and symptoms through fast and convenient access to information and products. Although there are some inevitable concerns, retail websites support the current trend toward selfdiagnosis and management of allergy, in line with national and international policies that encourage individuals to take greater responsibility for their own health. Piera Morlacchi, PhD* Carly A. Szasz, BM, BSy Joanne Wade, BM, BSy Anthony J. Frew, MD, FRCPz Helen E. Smith, DM, FFPHMy *Department of Business and Management School of Business, Management and Economics University of Sussex Sussex, England y Division of Public Health and Primary Care Brighton & Sussex Medical School z Department of Respiratory Medicine Brighton and Sussex University Hospitals NHS Trust Brighton, England [email protected]
References [1] Powell JA, Darvell M, Gray JAM. The doctor, the patient and the world-wide web: how the internet is changing healthcare. J R Soc Med. 2003;96:74e76. [2] Brass EP. Changing the status of drugs from prescription to over-the-counter availability. N Engl J Med. 2001;345:810e816. [3] Bessell TL, Anderson JN, Silagy CA, Sansom LN, Hiller JE. Surfing, self medicating and safety: buying non prescription and complementary medicines via the internet. Qual Saf Health Care. 2003;12:88e92.
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Letters / Ann Allergy Asthma Immunol 112 (2014) 71e82
[4] Zuckerman G, Bielory L. Complementary and alternative medicine herbal therapies for atopic disorders. Am J Med. 2002;113:47Se51S. [5] eBay UK Facts and Figures [online]. 2012. http://pages.ebay.co.uk/aboutebay/ thecompany/companyoverview.html. Accessed August 10, 2012.
[6] Smith HE, Wade J, Frew AJ. What does eBay offer the patient with allergy? Clin Exp Allergy. 2007;37:1878. [7] Eurostat database. http://epp.eurostat.ec.europa.eu/portal/page/portal/statistics/ search_database. Accessed August 20, 2012.
Puberty and asthma in a cohort of Swedish children The shift in asthma prevalence from male to female predominance during the pubertal years is believed to result from an increased incidence among girls rather than remission among boys.1,2 Moreover, from the pubertal years onward, airway hyperresponsiveness, a classic feature of asthma, also worsens among girls but improves in boys.3 Asthma medication use, a proxy for asthma severity, follows a similar pattern, with females requiring greater medication from puberty onward.2,4 These observations support the potential involvement of sexspecific factors with asthma during this period. However, all physical changes of pubertal development cannot be considered equally in relation to asthma, particularly among girls. Menarche appears to play a substantial role in asthma presence and timing of onset. Early menarche predicts poorer lung function5 and higher postmenarchal asthma incidence6 compared with average to late menarchal age. To better understand the associations between puberty and asthma, we aimed to assess associations between pubertal staging and asthma symptoms and treatment in a longitudinal, population-based cohort of Swedish children (Barn Allergi Milieu Stockholm Epidemiologi [BAMSE]) born in 1994-1996.7 The original cohort of 4089 infants was representative of the study catchment area, except for higher rates of parental smoking among nonresponders.7 Participant characteristics did not differ between those followed up through year 12 and those lost to attrition.8 At years 8 and 12, parents completed questionnaires on wheeze frequency in the previous 12 months and asthma medication. Subjects were deemed to have asthma based on parental reports of 4 or more episodes of wheeze or 1 or more episode of wheeze in combination with inhaled corticosteroid use in the past 12 months. Pubertal incidence of asthma was defined as no asthma at year 8 but asthma at year 12. At year 12, children responded to pubertal development questions based on the composite pubertal scoring system the Peterson index.9 Data were collected on 3 measures for both boys and girls (skin changes, linear growth spurt, and pubic hair growth), 2 measures for boys (voice change and beard growth), and 2 measures for girls (breast development and menarche). This scoring system permits the inclusion of the multiple characteristics of pubertal development along a continuum. For boys, all characteristics contributed equally. Girls reporting menarche by year 12 were considered to be in late puberty or postpuberty, regardless of other characteristics. Participants were then categorized into 1 of 5 mutually exclusive categories: prepuberty, early puberty, middle puberty, late puberty, or postpuberty. We further considered menarche independent of pubertal staging. We used binomial logistic regression to analyze these data and report odds ratios (ORs) and corresponding 95% confidence Disclosures: Dr Protudjer was supported by European Respiratory Society Long Term Research Fellowship grant 117-2011 and subsequently a Canadian Institutes of Health Research Post-Doctoral Fellowship during this project. Funding Sources: The BAMSE study was supported by Stockholm County Council, the Swedish Research Council, the Swedish Council for Working Life and Social Research, the Swedish Heart and Lung Foundation, the Swedish Asthma and Allergy Association, and the Swedish Foundation for Health Care Science and Allergy Research. Financial support was also provided through the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, grants 80748301 and 2011-3060 from the Swedish Research Council, and the Strategic Research Program in Epidemiology at Karolinska Institutet.
intervals (CIs) for unadjusted analyses and models adjusted for confounding by age at year 12. Analyses were performed with STATA statistical software, version 11.0 (StatCorp LP, College Station, Texas). Permission for this study was obtained from the Regional Ethical Review Board of the Karolinska Institutet, Stockholm, Sweden. At year 12, the response rate was 82% (3,366 of 4,089 patients), with asthma status available for 99% (3,339 of 3,366 patients). We excluded those for whom pubertal data were unavailable. This method yielded a sample of 2,721 (67% of the original cohort), of whom 50.2% were boys. Nearly all boys (1,347 of 1,378 [97.8%]) were in prepuberty, early puberty, or middle puberty. Nearly half of the girls (651 of 1,368 [47.6%]) were in late puberty or postpuberty. Thus, we created sex-specific pubertal staging categories. Boys were trichotomized into prepuberty, early puberty, or middle or late puberty (none reported postpuberty). Girls were trichotomized as prepuberty or early puberty, middle puberty, or late puberty or postpuberty. Approximately half of the girls (47.6%) reported menarche by year 12. Compared with boys, girls had a lower odds of asthma at each assessment (eg, year 8: OR, 0.66; 95% CI, 0.47-0.92; year 12: OR, 0.57; 95% CI, 0.42-0.78). Pubertal staging was not found to be associated with asthma presence vs absence in boys (Table 1). In contrast, girls being in late puberty or postpuberty was inversely associated with asthma at year 12 (OR, 0.35; 95% CI, 0.16-0.78). Among girls only, the odds of pubertal incidence of asthma vs asthma at neither year 8 nor year 12 decreased with more advanced pubertal staging (middle puberty: OR, 0.36; 95% CI, 0.15-0.88; late puberty or postpuberty: OR, 0.25; 95% CI, 0.09-0.68) (Table 2). Menarche and asthma presence at year 12 (OR, 0.58; 95% CI, 0.33-1.02) and menarche and pubertal incidence of asthma (OR, 0.56; 95% CI, 0.26-1.19) followed a similar trend, although these results did not reach statistical significance. In neither sex was pubertal staging associated with asthma medication use at year 12. Table 1 Logistic regression of cross-sectional associations between pubertal staging and asthma presence at year 12 Pubertal stage
Boys Prepuberty Early puberty Middle to late puberty Girls Prepuberty to early puberty Middle puberty Late puberty to postpuberty Menarche No Yes
Asthma presence vs absence at year 12 Presence, No.
Absence, No.
Unadjusted OR (95% CI)
Adjusted OR (95% CI)a
28 59 28
321 535 395
1.00 1.26 (0.79-2.02) 0.81 (0.47-1.40)
1.00 1.16 (0.71-1.90) 0.67 (0.36-1.25)
13
148
1.00
1.00
28 26
523 617
0.61 (0.31-1.21) 0.48 (0.24-0.96)b
0.54 (0.27-1.09) 0.35 (0.16-0.78)c
41 26
671 617
1.00 0.69 (0.42-1.14)
1.00 0.58 (0.33-1.02)
Abbreviations: CI, confidence interval; OR, odds ratio. a Adjusted for age at year 12. b P < .05. c P < .01.
Letters / Ann Allergy Asthma Immunol 112 (2014) 71e82
Clinical assessment of allergen immunotherapy with differing doses of horse extract Allergen immunotherapy is an effective form of therapy for allergic rhinitis because of a wide variety of allergens, including animals. Exposure to horses through commercial and leisure activities is increasing, and people experience respiratory symptoms, including allergic rhinitis, with horse exposure.1 The effective doses have been described for immunotherapy with cat and dog extract.2,3 Five horse allergens have been described, including Equ c 1, Equ c 2 (lipocalins), Equ c 3 (serum albumin), Equ c 4, and Equ c 5 (unknown function).4 However, immunotherapy with horse extract has been less extensively studied. One previous study from Spain found clinical efficacy with one standardized extract of horse dander.5 However, there are few clinical data regarding efficacy with differing doses of horse extract, and it is unknown which dose is most effective. We report a clinical observation regarding our experience in patients with differing doses of immunotherapy with horse extract. Eight patients, ranging in age from 9 to 57 years, with allergic rhinitis symptoms on exposure to horse and positive skin prick test results to horse dander were treated with horse extract (1:20 wt/vol produced by Greer Laboratories). The doses ranged from 0.2 to 1.0 mL of horse extract (of a 5-mL immunotherapy vial). Subcutaneous immunotherapy was administered on a weekly basis starting with a 1:10,000 dilution to a maintenance dose of 0.5 mL (of a 5-mL vial) of a 1:10 dilution. Three patients were treated with 0.3 mL of horse extract, 3 patients were treated with 0.25 mL of horse extract, 1 patient was treated with 0.2 mL of horse extract, and 1 patient was treated with 1.0 mL of horse extract (Table 1). Total nasal symptom scores (TNSSs) to horse exposure were recorded before initiation of immunotherapy and on reaching maintenance dose (Table 1). Nasal congestion, sneezing, rhinorrhea, and nasal itch were scored from 0 to 3 (0 indicating no symptoms; 1, mild symptoms; 2, moderate symptoms; and 3, severe symptoms), with the maximum score being 12.6 The mean TNSS score of all the treated patients before initiation of therapy was 8.5, and the mean TNSS score after arrival at the maintenance dose was 2.25. Statistical analysis of the data was performed by use of StatPac software (StatPac Inc, Bloomington, Minnesota). A matchedpairs t test between means was calculated, showing a significant difference in means before and after treatment (P ¼ .004). No adverse events were caused by the immunotherapy. Our clinical observation shows improvement with horse allergen extract immunotherapy.
Disclosures: The authors have nothing to disclose.
Table 1 Effect of differing doses of horse allergen immunotherapy Patient Horse extract dose TNSS before horse TNSS after horse age, y/sex (in a 5-mL vial), mL extract immunotherapy extract immunotherapy 44/F 35/F 45/F 15/F 9/M 57/F 9/F 46/M
0.2 0.25 0.25 0.25 0.3 0.3 0.3 1.0
12 4 8 4 12 8 12 8
4 0 5 0 1 8 0 0
Abbreviation: TNSS, Total Nasal Symptom Score.
In the future, additional larger studies may be performed to assess which exact dose is most clinically effective and to assess titrated skin prick responses, horse dander specific IgE and IgG4 levels, and analysis of CD4þ/CD25þ suppressor T cells in patients undergoing immunotherapy with horse allergen extract. Anil Nanda, MD*,y Anita N. Wasan, MDz *Asthma and Allergy Center Lewisville, Texas y Division of Allergy and Immunology University of Texas Southwestern Medical Center Dallas, Texas z Allergy and Asthma Center Lansdowne, Virginia [email protected] References [1] Mazan MR, Svatek J, Maranda L, et al. Questionnaire assessment of airway disease symptoms in equine barn personnel. Occup Med. 2009;59:220e225. [2] Nanda A, O’Connor M, Anand M, et al. Dose dependence and time course of the immunologic response to administration of standardized cat allergen extract. J Allergy Clin Immunol. 2004;114:1339e1344. [3] Lent A, Harbeck R, Strand M, et al. Immunologic response to administration of standardized dog allergen extract at differing doses. J Allergy Clin Immunol. 2006;118:1249e1256. [4] Weber RW. On the Cover: horse dander. Ann Allergy Asthma Immunol. 2010;105:A12. [5] Fernandez-Tavora L, Rico P, Martin S. Clinical experience with specific immunotherapy to horse dander. J Investig Allergol Clin Immunol. 2002;12:29e33. [6] Nicholson G, Kariyawasam H, Tan A, et al. The effects of an anti-IL-13 mAb on cytokine levels and nasal symptoms following nasal allergen challenge. J Allergy Clin Immunol. 2011;128:800e807.
Allergy products traded on eBay, 2007-2012 Use of the Internet has increased significantly since 2000, and it is increasingly being used for health information and health care delivery.1 The Internet also provides online marketplaces that facilitate purchase and trade of health care products, including some drugs that were previously only available by prescription.2,3 Allergic conditions are common, and there is a trend toward self-diagnosis and treatment. Understandably, most patients with allergic conditions wish to improve their quality of life and engage in normal recreational and occupational activities. Often they modify their behavior Disclosures: Authors have nothing to disclose.
or purchase over-the-counter medicines or alternative therapies, without necessarily feeling the need to seek medical advice.4 Many allergy-related products are available online. eBay.co.uk was launched in 1999 and is the United Kingdom’s largest and most visited online retail website, with more than 14 million active users who sell and buy through auctions every month.5 We examined the type and range of allergy-related products available on eBay.co.uk between January 2007 and August 2012 and reviewed the implications for people with allergy. The website (www.ebay.co.uk) was searched using the term allergy during 5 separate periods: January
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77
Table 1 Number of items and relative increase in allergy products advertised on eBay.co.uk 2007d2012 Categories of Products
January 2007
June 2009
July 2012
January 2007 (%)
June 2009 (%)
July 2012 (%)
Products for the home Hypoallergenic items Books Pharmaceuticals Alternative therapies Other Overall
185 10 14 12 10 16 247
612 216 362 101 88 106 1485
969 1238 1208 298 252 366 4331
75 4 6 5 4 6 100
41 15 24 7 6 7 100
22 29 28 7 6 8 100
2007,6 June 2007, June 2009, January to February 2012, and July to August 2012. In each period we collected data at 10 AM on 5 days during 2 consecutive weeks. In July to August 2012, data were collected at 4 additional times of day to track within-day changes of individual categories and subcategories. Seven main groups of products were identified: home products, books, hypoallergenic items, pharmaceuticals, alternative therapies, diagnostic tests, and other. Each of these groups was then further subcategorized. Home products included items intended to reduce allergens within the home, such as vacuum cleaners and their associated parts, cleaning materials, bedding, and pet supplies. Books were subdivided into cookery books, patient information materials, information books for children, and a combined subcategory of medical textbooks and clinical research books. Hypoallergenic items included jewelry, toiletries, and cosmetics. Alternative therapies included light therapy, healing crystals, skin balms, herbal tablets, vitamins, and supplements. Diagnostic tests ranged from conventional allergen IgE tests for grass pollen to alternative tests using hair or fingertip blood samples. Other products included medical alert bracelets, tickets for an allergy show, a trading card game, and supermarket club card points. Between 2007 and 2012, the proportion of UK Internet users selling any type of goods or services online via auction doubled (from 13.5% to 27%),7 whereas the daily mean number of allergy-related items sold on eBay.co.uk increased from 247 to 4,295. In 2007, more than 75% of all items were products for the home, but by 2012 this had decreased to 22%. Hypoallergenic products increased from 4% in 2007 to 29% in 2012, whereas books increased from 6% to 28% (Table 1). Pharmaceuticals, allergy tests, alternative therapies, and others all increased in absolute numbers but remained stable as a proportion of the total. The most frequently traded category was books, with a mean daily turnover greater than 3% in 2012. Within the home products category, bedding for adults and infants increased from 49% in 2007 to 71% in 2012. Among hypoallergenic products, jewelry increased from 8% in 2009 to 20% in 2012. The proportion of clinical textbooks has increased markedly, to 22% of all books on offer. During the last 5 years, a wide range of allergy products have been auctioned and traded daily on eBay. Most of these products aim to reduce exposure to allergens (either home products or hypoallergenic items, such as jewelry). Across the board there is a trend for more products being traded for allergic conditions in children. Although the overall number within each category has increased, there has been relative growth in hypoallergenic items and booksdnot just clinical textbooks but also books providing cookery and patient information, suggesting that people are trying to manage their allergies and educate themselves about their condition. As with other health care areas, accessing products for allergy online could benefit consumers and patients, but there are concerns about the safety and efficacy of online products, particularly about the safe and appropriate use of nonprescription medicines purchased online. With increasing choice comes increased uncertainty for consumers and patients. Not all products offered
are trustworthy, and the casual customer may find it difficult to distinguish what is useful for them and what is inappropriate. In part the increased number of auctions reflects the increasing commercialization of eBay, with major manufacturers and retailers using this route to promote their products. Together with more stringent regulations and higher fees for sellers, this trend has reduced the visibility of individual advertisers and, paradoxically, has narrowed the range of available products even though the volume of advertised products increases. Although our study focused on the United Kingdom, eBay is a global phenomenon, with 12.5 million auctions daily across 28 markets. We conducted a parallel analysis of eBay.com in July to August 2012. Although there were slightly more items on offer (mean, 5,294 items), the only significant difference was the relative higher proportion of over-the-counter medicines (18%) and alternative therapies (12%) traded on eBay.com compared with eBay.co.uk. A total of 14% of advertised items were products for the home and 15% were books. In conclusion, the number of allergy-related products available on eBay.co.uk increased 17-fold between 2007 and 2012. This is probably mirrored in other Internet marketplaces. The availability of these items may help people with allergies manage their conditions and symptoms through fast and convenient access to information and products. Although there are some inevitable concerns, retail websites support the current trend toward selfdiagnosis and management of allergy, in line with national and international policies that encourage individuals to take greater responsibility for their own health. Piera Morlacchi, PhD* Carly A. Szasz, BM, BSy Joanne Wade, BM, BSy Anthony J. Frew, MD, FRCPz Helen E. Smith, DM, FFPHMy *Department of Business and Management School of Business, Management and Economics University of Sussex Sussex, England y Division of Public Health and Primary Care Brighton & Sussex Medical School z Department of Respiratory Medicine Brighton and Sussex University Hospitals NHS Trust Brighton, England [email protected]
References [1] Powell JA, Darvell M, Gray JAM. The doctor, the patient and the world-wide web: how the internet is changing healthcare. J R Soc Med. 2003;96:74e76. [2] Brass EP. Changing the status of drugs from prescription to over-the-counter availability. N Engl J Med. 2001;345:810e816. [3] Bessell TL, Anderson JN, Silagy CA, Sansom LN, Hiller JE. Surfing, self medicating and safety: buying non prescription and complementary medicines via the internet. Qual Saf Health Care. 2003;12:88e92.
78
Letters / Ann Allergy Asthma Immunol 112 (2014) 71e82
[4] Zuckerman G, Bielory L. Complementary and alternative medicine herbal therapies for atopic disorders. Am J Med. 2002;113:47Se51S. [5] eBay UK Facts and Figures [online]. 2012. http://pages.ebay.co.uk/aboutebay/ thecompany/companyoverview.html. Accessed August 10, 2012.
[6] Smith HE, Wade J, Frew AJ. What does eBay offer the patient with allergy? Clin Exp Allergy. 2007;37:1878. [7] Eurostat database. http://epp.eurostat.ec.europa.eu/portal/page/portal/statistics/ search_database. Accessed August 20, 2012.
Puberty and asthma in a cohort of Swedish children The shift in asthma prevalence from male to female predominance during the pubertal years is believed to result from an increased incidence among girls rather than remission among boys.1,2 Moreover, from the pubertal years onward, airway hyperresponsiveness, a classic feature of asthma, also worsens among girls but improves in boys.3 Asthma medication use, a proxy for asthma severity, follows a similar pattern, with females requiring greater medication from puberty onward.2,4 These observations support the potential involvement of sexspecific factors with asthma during this period. However, all physical changes of pubertal development cannot be considered equally in relation to asthma, particularly among girls. Menarche appears to play a substantial role in asthma presence and timing of onset. Early menarche predicts poorer lung function5 and higher postmenarchal asthma incidence6 compared with average to late menarchal age. To better understand the associations between puberty and asthma, we aimed to assess associations between pubertal staging and asthma symptoms and treatment in a longitudinal, population-based cohort of Swedish children (Barn Allergi Milieu Stockholm Epidemiologi [BAMSE]) born in 1994-1996.7 The original cohort of 4089 infants was representative of the study catchment area, except for higher rates of parental smoking among nonresponders.7 Participant characteristics did not differ between those followed up through year 12 and those lost to attrition.8 At years 8 and 12, parents completed questionnaires on wheeze frequency in the previous 12 months and asthma medication. Subjects were deemed to have asthma based on parental reports of 4 or more episodes of wheeze or 1 or more episode of wheeze in combination with inhaled corticosteroid use in the past 12 months. Pubertal incidence of asthma was defined as no asthma at year 8 but asthma at year 12. At year 12, children responded to pubertal development questions based on the composite pubertal scoring system the Peterson index.9 Data were collected on 3 measures for both boys and girls (skin changes, linear growth spurt, and pubic hair growth), 2 measures for boys (voice change and beard growth), and 2 measures for girls (breast development and menarche). This scoring system permits the inclusion of the multiple characteristics of pubertal development along a continuum. For boys, all characteristics contributed equally. Girls reporting menarche by year 12 were considered to be in late puberty or postpuberty, regardless of other characteristics. Participants were then categorized into 1 of 5 mutually exclusive categories: prepuberty, early puberty, middle puberty, late puberty, or postpuberty. We further considered menarche independent of pubertal staging. We used binomial logistic regression to analyze these data and report odds ratios (ORs) and corresponding 95% confidence Disclosures: Dr Protudjer was supported by European Respiratory Society Long Term Research Fellowship grant 117-2011 and subsequently a Canadian Institutes of Health Research Post-Doctoral Fellowship during this project. Funding Sources: The BAMSE study was supported by Stockholm County Council, the Swedish Research Council, the Swedish Council for Working Life and Social Research, the Swedish Heart and Lung Foundation, the Swedish Asthma and Allergy Association, and the Swedish Foundation for Health Care Science and Allergy Research. Financial support was also provided through the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, grants 80748301 and 2011-3060 from the Swedish Research Council, and the Strategic Research Program in Epidemiology at Karolinska Institutet.
intervals (CIs) for unadjusted analyses and models adjusted for confounding by age at year 12. Analyses were performed with STATA statistical software, version 11.0 (StatCorp LP, College Station, Texas). Permission for this study was obtained from the Regional Ethical Review Board of the Karolinska Institutet, Stockholm, Sweden. At year 12, the response rate was 82% (3,366 of 4,089 patients), with asthma status available for 99% (3,339 of 3,366 patients). We excluded those for whom pubertal data were unavailable. This method yielded a sample of 2,721 (67% of the original cohort), of whom 50.2% were boys. Nearly all boys (1,347 of 1,378 [97.8%]) were in prepuberty, early puberty, or middle puberty. Nearly half of the girls (651 of 1,368 [47.6%]) were in late puberty or postpuberty. Thus, we created sex-specific pubertal staging categories. Boys were trichotomized into prepuberty, early puberty, or middle or late puberty (none reported postpuberty). Girls were trichotomized as prepuberty or early puberty, middle puberty, or late puberty or postpuberty. Approximately half of the girls (47.6%) reported menarche by year 12. Compared with boys, girls had a lower odds of asthma at each assessment (eg, year 8: OR, 0.66; 95% CI, 0.47-0.92; year 12: OR, 0.57; 95% CI, 0.42-0.78). Pubertal staging was not found to be associated with asthma presence vs absence in boys (Table 1). In contrast, girls being in late puberty or postpuberty was inversely associated with asthma at year 12 (OR, 0.35; 95% CI, 0.16-0.78). Among girls only, the odds of pubertal incidence of asthma vs asthma at neither year 8 nor year 12 decreased with more advanced pubertal staging (middle puberty: OR, 0.36; 95% CI, 0.15-0.88; late puberty or postpuberty: OR, 0.25; 95% CI, 0.09-0.68) (Table 2). Menarche and asthma presence at year 12 (OR, 0.58; 95% CI, 0.33-1.02) and menarche and pubertal incidence of asthma (OR, 0.56; 95% CI, 0.26-1.19) followed a similar trend, although these results did not reach statistical significance. In neither sex was pubertal staging associated with asthma medication use at year 12. Table 1 Logistic regression of cross-sectional associations between pubertal staging and asthma presence at year 12 Pubertal stage
Boys Prepuberty Early puberty Middle to late puberty Girls Prepuberty to early puberty Middle puberty Late puberty to postpuberty Menarche No Yes
Asthma presence vs absence at year 12 Presence, No.
Absence, No.
Unadjusted OR (95% CI)
Adjusted OR (95% CI)a
28 59 28
321 535 395
1.00 1.26 (0.79-2.02) 0.81 (0.47-1.40)
1.00 1.16 (0.71-1.90) 0.67 (0.36-1.25)
13
148
1.00
1.00
28 26
523 617
0.61 (0.31-1.21) 0.48 (0.24-0.96)b
0.54 (0.27-1.09) 0.35 (0.16-0.78)c
41 26
671 617
1.00 0.69 (0.42-1.14)
1.00 0.58 (0.33-1.02)
Abbreviations: CI, confidence interval; OR, odds ratio. a Adjusted for age at year 12. b P < .05. c P < .01.
