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

  • J. BousquetEmail author
  • P. W. Hellings
  • I. Agache
  • A. Bedbrook
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Open Access
Review

Abstract

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

Keywords

ARIA Rhinitis ICT EIP on AHA Mobile technology AIRWAYS ICPs 

Abbreviations

AIRWAYS ICPs

integrated care pathways for airway diseases

AR

allergic rhinitis

ARIA

Allergic Rhinitis and its Impact on Asthma

CDSS

Clinical Decision Support System

COPD

chronic obstructive pulmonary disease

DG

Directorate General

EAACI

European Academy of Allergy and Clinical Immunology

EIP on AHA

European Innovation Partnership on Active and Healthy Ageing

EU

European Union

FP

Framework Programme (EU)

GA2LEN

Global Allergy and Asthma European Network (FP6)

GARD

WHO Global Alliance against Chronic Respiratory Diseases

GRADE

Grading of Recommendation, Assessment, Development and Evaluation

HCP

health care professional

ICP

integrated care pathway

IPCRG

International Primary Care Respiratory Group

MACVIA-LR

Contre les Maladies Chroniques pour un Vieillissement Actif (fighting chronic diseases for active and healthy ageing)

MASK

MACVIA-ARIA Sentinel NetworK

MeDALL

Mechanisms of the Development of ALLergy (EU FP7)

MOH

Ministry of Health

NCD

non-communicable disease

NHS

National Health Service

RCT

randomized controlled trial

RQLQ

Rhinoconjunctivitis Quality of Life Questionnaire

RSCN

Reference Site Collaborative Network

SCUAD

severe chronic upper airway disease

VAS

visual analogue scale

WHO

World Health Organization

Background

The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization (WHO) workshop in 1999 (published in 2001) [1]. The goals were (1) to propose a new allergic rhinitis (AR) classification using persistence and severity of symptoms in order to more closely reflect patients’ needs, (2) to promote the concept of multi-morbidity in asthma and rhinitis as a key factor for patient management, (3) to develop guidelines with all stakeholders, (4) to include experts from developed and developing countries and (5) to initiate global implementation among health care professionals (HCPs) and patients.

Patients, clinicians and other HCPs are confronted with various treatment choices for the management of AR. This contributes to considerable variation in clinical practice. Worldwide, patients, clinicians and other HCPs are faced with uncertainty about the relative merits and downsides of the many AR treatment options available. The first ARIA workshop report used the Shekelle evidence-based methodology [1, 2]. It was the first guideline in chronic disease to assess multi-morbid conditions (i.e. asthma and rhinitis in the same patient). In 2008, ARIA was updated using the same evidence-based system [3]. More transparent reporting of guidelines to facilitate understanding and acceptance was needed. In its 2010 Revision, ARIA was the first chronic respiratory disease guideline to adopt the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) approach, an advanced evidence evaluation methodology [4, 5, 6, 7]. A new revision is pending.

ARIA has been disseminated and is implemented in over 70 countries around the world [8]. It is now focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK [MACVIA (Contre les Maladies Chroniques pour un Vieillissement Actif)-ARIA Sentinel NetworK] uses mobile technology to develop care pathways for the management of rhinitis and asthma by a multi-disciplinary group and by patients themselves [9].

The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status in order to reduce health and social inequalities incurred by the disease.

AIRWAYS ICPs: the ARIA 2016 political agenda

In 2012, the European Commission launched the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA; DG Santé and DG CONNECT) to enhance EU competitiveness and tackle societal challenges through research and innovation [10]. The B3 Action Plan is devoted to the scaling up and replication of successful innovative integrated care models for chronic diseases amongst older patients.

Chronic respiratory diseases were selected to be the pilot for chronic diseases of the EIP on AHA Action Plan B3 (Integrated care pathways for airway diseases, AIRWAYS ICPs) [11, 12] with a life cycle approach [13]. Several effective plans exist in Europe for chronic respiratory diseases, but they are rarely deployed to other regions or countries.

AIRWAYS ICPs aims to launch a collaboration to develop practical multi-sectoral care pathways (i.e. ICPs) in European countries and regions to reduce chronic respiratory disease burden, mortality and multi-morbidity, while maintaining patients’ quality-of-life (QOL) [11, 14]. AIRWAYS-ICPs proposes a feasible, achievable and manageable project (from science to guidelines and policies) using existing networks. It brings together key stakeholders including end users, public authorities, industry partners, involved in the innovation cycle, from research to adoption, as well as those engaged in standardisation and regulation. The Action Plan of AIRWAYS ICPs has been devised [11], implemented [14] and scaled up [15].

AIRWAYS ICPs is a GARD (WHO Global Alliance against Chronic Respiratory Diseases) [16] research demonstration project. Its deployment beyond Europe is carried out via GARD.

One AIRWAYS-ICPs activity is the development of multi-sectoral care pathways for rhinitis and asthma and their multi-morbidities, implementing emerging technologies for predictive medicine across the patient life cycle [13].

From guidelines to integrated care pathways: MACVIA-ARIA Sentinel NetworK (MASK)

Best practice, guideline and care pathways

A good or best practice is a technique, method, process, activity, incentive, or reward believed to be more effective than any other technique, method, process, etc. when applied to a particular condition or circumstance. A best practice can be adopted as a standard process or be used as a guideline (U.S. Dept. of Veterans Affairs [17]).

A guideline is a statement to determine a course of action. It aims to streamline particular processes according to a set routine or sound practice. By definition, following a guideline is never mandatory. Guidelines are not binding and are not enforced (U.S. Dept. of Veterans Affairs [17]).

Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” (Institute of Medicine, 1990). These clinical practice guidelines define the role of specific diagnostic and treatment modalities. The statements include recommendations based on evidence intended to help HCPs and providers in their practice [18].

The Integrated Care Pathway (ICP) concept was initiated in 1985 by Zander and Bower [19]. ICPs are structured multi-disciplinary care plans detailing key steps of patient care for a given clinical problem [20]. They promote the translation of guidelines into local protocols and their subsequent application to clinical practice. An ICP forms all or part of the clinical record, documents the care given, and facilitates the evaluation of outcomes for continuous quality improvement [21]. They can help empower patients and their carers (health and social). ICPs differ from clinical practice guidelines as they are utilized by a multi-disciplinary team, and focus on the quality and co-ordination of care. ICPs need to have a mechanism for recording variations/deviations from planned care. Like guidelines, an ICP is a guide to treatment, and clinicians are free to exercise their own professional judgment as appropriate. However, any alteration to the practice identified within this ICP must be noted as a variance [22]. Variance analysis is a critical part of developing and using ICPs [23]. The resulting analysis can be used to amend the ICP itself if, for the majority of patients, the practice is different to the pathway (Table 1).
Table 1

Definition of guidelines, practice protocols and ICPs.

Adapted from http://www.implementationcentral.com/guidelines_8.html

 

Guideline

Clinical practice guidelines

Care pathway

Focus

Specific clinical circumstances

Treatment and/or prevention

The quality and co-ordination of care

Definition

Systematically developed statements to help practitioners and patients make decisions about appropriate health care

A suggested course of treatment and/or treatment service for a specific diagnosis, functional deficit or problem area

Structured, multi-disciplinary plans of care

Goals

Makes specific recommendations on health care and links these to research evidence

Highlights major therapeutic or preventive interventions

Identifies choices of different courses or paths of treatment

Supports the implementation of clinical guidelines and protocols

Outputs

Provides a summary and appraisal of the best available research evidence or expert consensus

Highlights the strength of the evidence underlying each recommendation

Describes barriers and facilitators for each recommendation

Provides a logical flow of interventions. Provides detailed recommendations that build on those made in SPCs guidelines

Provides detailed guidance for each stage in the management of a patient and key performance indicators

Users

Clinicians, patients and third parties (all stakeholders involved)

Specific to clinicians

A multidisciplinary clinical team

Components

(1) Appraisal of literature (research evidence or expert consensus)

(2) Summary of recommendations

(3) An outline of how guidelines should be implemented and how adherence monitored

List of major therapeutic or preventive interventions

Goals: When interventions should be achieved

Options for different choices of treatment and/or prevention

(1) Timeline

(2) Categories of care/intervention

(3) Intermediate and long term outcome criteria

(4) A variance record

Multisectoral care pathways for rhinitis and asthma using ICT

A large number of AR patients do not consult physicians because they think their AR symptoms are ‘normal’ and/or trivial. However, AR negatively impacts social life, school and work productivity [3]. Many AR patients use over the counter (OTC) drugs [24] and only a fraction have had a medical consultation. The vast majority of patients who visit GPs or specialists have moderate/severe rhinitis [25, 26, 27, 28, 29]. Thus, ICPs should consider a multi-disciplinary approach as proposed by AIRWAYS ICPs (Fig. 1).
Fig. 1

Multi-sectoral care pathway for allergic rhinitis (from Bousquet et al. [9])

The variations/deviations of the ARIA recommendations from planned care have been assessed and several unmet needs identified. Disease severity is associated with several health outcomes, including quality of life [25, 26, 27, 28, 29], and should be considered in ICPs. The duration of rhinitis (intermittent/severe-persistent) is an important indicator of asthma multi-morbidity (in some but not all studies) [30], duration of AR treatment and efficacy of treatment in AR [27]. Most patients receive combinations of oral antihistamines and intra-nasal corticosteroids (INS) [31, 32, 33] which are not evaluated in guidelines using an appropriate methodology.

Simple approach to assess control in allergic rhinitis

In asthma, the management strategy is based on disease control, current treatment and future risk (exacerbations, lung function decline) [34, 35, 36]. In AR, the switch from symptom severity to disease control to guide treatment decisions has been led by ARIA and is now expanding to include MACVIA (a reference site of the EIP on AHA, EU [37]) to form an Action Plan (MACVIA-ARIA). New developments which have facilitated this process include (1) the introduction of the visual analogue scale (VAS) as the common validated language of AR control, (2) categorization of AR control using VAS score cut-offs, (3) incorporation of this VAS into simple interactive apps for both patients (ARIA Allergy Diary) and HCPs (ARIA Allergy Diary Companion) [9, 38] and (4) the integration of all this knowledge into ICPs deployed by the EIP on AHA [9].

The VAS represents a simple way of measuring control. It has been used in many diseases, including AR. VAS scores appear to be similar in different countries, for patients with moderate–severe intermittent or persistent rhinitis [39, 40]. An advantage of the VAS is that it can be used in all age groups, including preschool children (guardian evaluation) [41] and the elderly [42, 43]. Furthermore, it can be used in a wide variety of languages [39, 40, 42, 44, 45, 46, 47, 48]. VAS scores vary with ARIA AR classification in many languages [28, 44, 49, 50]. A VAS score of 50/100 mm suggests moderate–severe AR [32, 51, 52], although in some studies this cut-off was >60 mm [45]. The VAS has been used to define severe chronic upper airway disease (SCUAD [53]). The minimal clinically important difference (MCID) during treatment was found to be 2.3/10 cm in the French population [54] and may be generalized to other countries, but future studies may refine this cut-off score. VAS score changes appear to encompass both symptoms and disease-specific QOL [54, 55].

As is the case for asthma, the best control of AR should be achieved as early as possible in order to (1) improve patient satisfaction and concordance with treatment and (2) reduce the AR burden including symptoms, reduced QoL, and school and work presenteeism/absenteeism. Untreated AR can impair driving ability and put patients at risk [56]. The ultimate goal of AR control is to reduce the direct and indirect costs incurred by AR [57, 58, 59, 60].

The variability in approaches to achieve disease control is challenging, and necessitates careful monitoring as well as the step up/step down of individualized therapeutic regimens over time. However, the challenges of managing AR are increased by the fact that patients do not often recognise their AR symptoms or confuse them with those of asthma or other multimorbidities such as rhinosinusitis [61]. Therefore, it is important for patients, caregivers or HCPs to be able to use an AR symptom scoring system that is simple to use and rapidly responsive to change.

The aim is to encourage effective cross communication and achieve rapid and sustained disease control. MACVIA-ARIA has produced a simple VAS-based algorithm called the ARIA Clinical Decision Support System (CDSS) using a VAS score to guide treatment decisions in a step-up/step-down approach. This CDSS provides an individualized approach to AR pharmacotherapy (depending on medication availability and resources) [62]. This approach holds the potential for optimal AR control while minimizing side effects and costs.

MASK (MACVIA-ARIA Sentinel NetworK): rhinitis and asthma

MASK-rhinitis and asthma is a simple ICT tool used to implement ICPs for AR and asthma by means of a common language (for patients and HCPs) and a CDSS. Disease control is assessed by VAS, incorporated into apps for patients (ARIA Allergy Diary) and HCPs (ARIA Allergy Diary Companion), with the utility to assess patient QoL (weekly EQ-5D) [63, 64] and school/work productivity (weekly WPAI-AS and daily VAS) [25, 65, 66].

MASK-rhinitis and asthma will (1) allow patients and caregivers to screen for AR and asthma, and track their AR control (2) guide pharmacists in the prescription of OTC medications and referral of patients to physicians when appropriate, (3) allow primary care physicians to prescribe appropriate AR treatment, assess patients’ AR control and direct follow-ups in accordance with the CDSS and (4) encourage referral to specialists and outpatient clinics, if there is failure to gain AR control at the primary care level.

MASK-rhinitis and asthma will be important for establishing care pathways across the life cycle. It will stratify patients with severe uncontrolled disease and achieve better results in prevention and intervention trials guided by the use of an individualised and predictive medicine approach.

The MASK tools: the ARIA Allergy Diary and ARIA Allergy Diary Companion apps

The ARIA Allergy Diary is freely available in 15 EU countries, Australia, Mexico and Switzerland and in 15 languages (translated and back-translated, culturally adapted and legally compliant). It will also be deployed in Brazil, Canada and the USA. The companion app will be available in Autumn 2016.

A pilot study was completed in AR during the pollen season to assess the relevance of the ARIA Allergy Diary app. It showed the importance of the tool to stratify patients, assess their work productivity and improve quality of life (EQ-5D) (Bousquet et al., submitted). Studies in asthma are planned for the autumn and winter.

Questionnaires

ARIA Allergy Diary users fill in simple questionnaires on asthma, rhinitis and the impact of the disease (globally, on work and school, on daily activities and on sleep) upon registration (Table 2). The pilot study in around 5000 users (9% over 60 years of age) indicates that these questions are easily answered and can help to stratify patients with rhinitis.
Table 2

Baseline questionnaire

Q1: I have rhinitis: yes/no

Q2: I have asthma: yes/no

Q3: My symptoms (tick)

 Runny nose

 Itchy nose

 Sneezing

 Congestion (blocked nose)

 Red eyes

 Itchy eyes

 Watery eyes

Q4: How they affect me: my symptoms (tick)

 Affect my sleep

 Restrict my daily activities

 Restrict my participation in school or work

 Are troublesome

Q5: Medications

Q6: Are you currently receiving immunotherapy (a small dose of the thing you are allergic to, usually taken as an injection or placed under your tongue)? yes/no

 If YES to Q6 (Q7 and Q8)

Q7: What allergy is this?

 Grass pollen

 Parietaria pollen

 Birch pollen

 Other pollen

 Dust mite

 Animal

 Cypress tree pollen

 Don’t know

 Add allergy

Q8: How do you receive your treatment?

 Injection

 Tablet under the tongue

 Drops under the tongue

 Spray under the tongue

 Other

Moreover, two specific questionnaires are applied every week to assess disease impact on patients’ QoL (EQ-5D) [63, 64] and productivity at work (WPAI-AS) [25, 65, 66].

Treatments received

A list of all treatments available for asthma, conjunctivitis and rhinitis is included in the ARIA Allergy Diary, and users select the treatment(s) they are taking. Multiple treatments may be selected, and users can update the information when (or if) their treatment changes (Fig. 2). The list has been customized for all 20 countries in which the ARIA Allergy Diary is available, using data from IMS Health. Information on allergen specific immunotherapy is also requested on the day of first use. A questionnaire on biologics for asthma is under development.
Fig. 2

Screens on medications

Daily visual analogue scales

Geolocalized users assess their daily symptom control using the touchscreen functionality on their smart phone to click on 5 consecutive VASs (global symptoms due to allergic diseases, rhinitis, conjunctivitis, asthma and work productivity) (Fig. 3). These scales have been validated for AR and asthma criteria [67, 68, 69, 70, 71] and for work productivity (Bousquet et al., in preparation).
Fig. 3

Screens on daily visual analogue scales

MASK-asthma

Besides the asthma VAS, a test to measure pulmonary function is being developed. It is expected to be added to the ARIA Allergy Diary by the end of 2016.

Clinical decision support system

The MASK CDSS is incorporated into an app for HCPs (i.e. ARIA Allergy Diary Companion). This is essentially an algorithm to aid clinicians to select pharmacotherapy for patients with AR and to stratify their disease severity [62]. It uses a simple step-up/step-down individualized approach to AR pharmacotherapy and may hold the potential for optimal control of symptoms, while minimizing side effects and costs. However, its use varies depending on the availability of medications in the different countries and on resources. A CDSS for asthma is also being developed.

Ethics

The terms of use have been translated into all languages and customized according to the country’s legislation. They allow the use of anonymous data for research and commercial purposes. The app has a CE registration as a medical device class 1.

Patient empowerment

The validation of the ARIA Allergy Diary has already been accomplished (manuscript in preparation). With the help of patient organisations (EFA: European Federation of Allergy and Airways Diseases Patients’ Associations), it will be evaluated and improved by the patients themselves.

New concepts in allergic multimorbidity embedded in ARIA

The term allergic multimorbidity is more appropriate than comorbidity since the primary allergic disease is poorly known [72].

Stratification of severe allergic and/or asthma patients

Despite the major advances in understanding allergic diseases or asthma, treatments are not effective in all patients. From a clinical perspective, implementing knowledge-based decisions on what therapeutics to use for which patients and, if relevant, in which combinations, is extremely challenging. The aspiration to provide more effective therapeutic interventions tailored to the individual remains unfulfilled because of the variable response of individuals to such interventions. Patient stratification aims at grouping patients into disease sub-groups, where the specific pathological processes involved are better defined (clinical/molecular phenotypes).

Long-term birth cohort studies are essential for understanding the life course, early predictors, risk and protective factors of allergic diseases (including asthma and rhinitis) and the complex interplay between genes and environment (including life style and socio-economic determinants) [73]. MeDALL (Mechanisms of the Development of ALLergy; EU FP7-CP-IP; Project No.: 261357; 2010–2015) attempted to better understand the complex links of allergic diseases at the clinical and mechanistic levels [74, 75, 76].

MeDALL identified a rare but severe allergy phenotype: polysensitized-multimorbid phenotype. Although multimorbidity is not always associated with allergy, studies in MeDALL [77] on children, in the PARIS cohort at 2 years of age [78], in EGEA on adults [79, 80] (Siroux, in preparation) and patient cohorts in subjects with peanut allergy [81] all show that subjects who are polysensitized and multimorbid have a very high frequency of allergic symptoms, persistent symptoms over time, more severe asthma symptoms than other phenotypes and higher total and specific IgE levels.

Taken altogether, these results indicate that asthmatic patients cannot be managed appropriately without assessing rhinitis multimorbidity and also reinforce the importance of nasal problems (rhinitis and/or rhinosinusitis) in many uncontrolled asthmatic patients [82, 83, 84].

Allergic multimorbidity in old age adults

Asthma and rhinitis often start in early age and persist in most, but not all, subjects. The expected epidemic wave of asthma and rhinitis in older adults is an insufficiently recognized problem. In Europe, over 20% of adults suffer from AR and over 5% from asthma. These patients are now reaching the age of 65 years and a new health problem in older adults will be to understand, detect and manage these patients. Asthma and rhinitis in older adults have specific symptoms and treatment needs, which are different from those in younger adults. These patients also suffer from multi-morbididy with high rates of poly-pharmacy reported. Integrated Care Pathways (ICPs) for rhinitis and asthma should cover the entire life cycle.

The scaling up strategy

The EIP on AHA has proposed a 5-step framework for developing an individual scaling up strategy: (1) what to scale up: (1-a) databases of good practices, (1-b) assessment of viability of the scaling up of good practices, (1-c) classification of good practices for local replication and (2) how to scale up: (2-a) facilitating partnerships for scaling up, (2-b) implementation of key success factors and lessons learnt, including emerging technologies for individualised and predictive medicine. This strategy has already been applied to the chronic respiratory diseases action plan of the EIP on AHA [15].

There is an urgent need for scaling up strategies in order to (1) avoid fragmentation, (2) improve health care delivery across Europe, (3) speed up the implementation of good practices using existing cost-effective success stories and (4) meet the EIP on AHA objectives [10].

Reference Site Collaborate Network (RSCN) of the EIP on AHA

The RSCN brings together all EIP on AHA Reference Sites, and Candidate Reference Sites, across Europe into a single forum. The aim is to promote cooperation and develop and promote areas of innovative good practice and solutions, which contribute to improved health and care outcomes for citizens across Europe. The hope is to develop sustainable economic growth and create jobs. Members of 13 EIP on AHA Reference Sites (2013) have agreed on the AIRWAYS ICPs concept and are co-authors of the paper published in Clinical Translational Allergy [15]. A meeting of all EIP on AHA Reference Sites was co-organised by the Région LR, North England [85] and the EIP on AHA Reference Site Collaborative Network to scale up AIRWAYS ICPs in all Reference Sites (October 21, 2014). 74 EIP on AHA Reference Sites have now been approved by the EU (2016). A Twinning project has also been approved by the EIP on AHA to deploy MASK in 13 Reference Sites in order to compare allergic rhinitis diagnoses by allergists in adults and older people to study phenotypes, treatments and care pathways of rhinitis.

Conclusion

ARIA has evolved from a rigorously developed guideline to a mobile technology-based implementation strategy in order to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status with the aim to reduce health and social inequalities incurred by this very common disease globally.

Notes

Authors’ contributions

All authors are participating to the ARIA and AIRWAYS ICPs projects globally. All authors participated in «ARIA 2016: Care pathways implementing emerging technologies for predictive medicine in rhinitis and asthma across the life cycle» . All authors read and approved the final manuscript.

Acknowledgements

Member of the dissemination of MASK in 20 countries: J. Bousquet, P. Hellings, A. Bedbrook, C. Bachert, K.C. Bergmann, M. Bewick, C. Bindslev-Jensen, S. Bosnic-Anticevitch, D. Caimmi, P.A.M. Camargos, G.W. Canonica, T. Casale, N.H. Chavannes, A.A. Cruz, G. De Carlo, R. Dahl, P. Demoly, P. Devillier, J. Fonseca, W.J. Fokkens, T. Haahtela, J. Just, L. Klimek, P. Kuna, D. Larenas-Linnemann, M. Morais-Almeida, J. Mullol, R. Murray, R. Naclerio, R.E. O’Hehir, N.G. Papadopoulos, P. Potter, D. Ryan, B. Samolinski, H.J. Schunemann, A. Sheikh, F.E.R. Simons, P.V. Tomazic, A. Valiulis, E. Valovirta, M. Wickman, A. Yorgancioglu, T. Zuberbier, S. Arnavielle, G. De Vries, G. Dray, M. van Eerd.

Twinning of MASK in Reference Sites of the European Innovation Partnership on Active and Healthy Ageing: J. Bousquet, A. Bedbrook, M. Bewick, C. Bindslev-Jensen, C. Bucca, D. Caimmi, N.H. Chavannes, P. Demoly, J. Fonseca, N.A. Guldemond, M. Illario, P. Kuna, M. Morais-Almeida, J. Mullol, R. Murray, C. Stellato, A. Todo-Bom, M.T. Ventura, I. Young, A. Yorgancioglu, S. Arnavielle, E. Ellers, J. Farrell, R. Gerth van Wick, Z. Gutter, G. Iaccarino, M. Olive-Elias.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Obtained from all authors.

Ethics approval and consent to participate

Review, none needed.

Funding

European Innovation Partnership on Active and Healthy Ageing Reference Site MACVIA-France, EU Structural and Development Fund Languedoc-Roussillon, ARIA.

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Authors and Affiliations

  • J. Bousquet
    • 1
    • 2
    • 3
    • 312
    Email author
  • P. W. Hellings
    • 4
  • I. Agache
    • 5
  • A. Bedbrook
    • 2
  • C. Bachert
    • 6
  • K. C. Bergmann
    • 7
    • 8
  • M. Bewick
    • 9
  • C. Bindslev-Jensen
    • 10
  • S. Bosnic-Anticevitch
    • 11
  • C. Bucca
    • 12
  • D. P. Caimmi
    • 13
  • P. A. M. Camargos
    • 14
  • G. W. Canonica
    • 15
  • T. Casale
    • 16
  • N. H. Chavannes
    • 17
  • A. A. Cruz
    • 18
    • 19
  • G. De Carlo
    • 20
  • R. Dahl
    • 18
  • P. Demoly
    • 13
    • 21
    • 22
  • P. Devillier
    • 23
  • J. Fonseca
    • 24
    • 25
    • 26
  • W. J. Fokkens
    • 27
  • N. A. Guldemond
    • 28
  • T. Haahtela
    • 29
  • M. Illario
    • 30
  • J. Just
    • 31
  • T. Keil
    • 32
    • 33
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    • 34
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    • 35
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    • 36
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  1. 1.Montpellier University HospitalMontpellierFrance
  2. 2.MACVIA-France, Contre les MAladies Chroniques pour un VIeillissement Actif en France, European Innovation Partnership on Active and Healthy Ageing Reference SiteMontpellierFrance
  3. 3.INSERM, U1168Ageing and Chronic Diseases Epidemiological and Public Health ApproachesVillejuifFrance
  4. 4.Laboratory of Clinical Immunology, Department of Microbiology and ImmunologyKU LeuvenLouvainBelgium
  5. 5.Transylvania University BrasovBrasovRomania
  6. 6.Upper Airways Research Laboratory, ENT DepartmentGhent University HospitalGhentBelgium
  7. 7.Allergy-Centre-Charité, Department of Dermatology and AllergyCharité - Universitätsmedizin BerlinBerlinGermany
  8. 8.Global Allergy and Asthma European Network (GA²LEN)BerlinGermany
  9. 9.iQ4U Consultants LtdLondonUK
  10. 10.Department of Dermatology and Allergy CentreOdense University HospitalOdenseDenmark
  11. 11.Woolcock Institute of Medical ResearchUniversity of Sydney and Sydney Local Health DistrictGlebeAustralia
  12. 12.University Pneumology Unit-AOU Molinette, Hospital City of Health and Science of TorinoTurinItaly
  13. 13.Department of Respiratory DiseasesMontpellier University HospitalMontpellierFrance
  14. 14.Department of Pediatrics, Medical SchoolFederal University of Minas GeraisBelo HorizonteBrazil
  15. 15.Asthma and Allergy ClinicHumanitas UniversityRozzano, MilanItaly
  16. 16.Division of Allergy/ImmunologyUniversity of South FloridaTampaUSA
  17. 17.Department of Public Health and Primary CareLeiden University Medical CenterLeidenThe Netherlands
  18. 18.ProAR – Nucleo de Excelencia em AsmaFederal University of BahiaSalvadorBrazil
  19. 19.GARD Executive CommitteeSalvadorBrazil
  20. 20.EFA European Federation of Allergy and Airways Diseases Patients’ AssociationsBrusselsBelgium
  21. 21.EPAR U707 INSERMParisFrance
  22. 22.EPAR UMR-S UPMC, Paris VIParisFrance
  23. 23.Laboratoire de Pharmacologie Respiratoire UPRES EA220Hôpital Foch, Suresnes Université VersaillesSaint-QuentinFrance
  24. 24.Center for Research in Health Technologies and Information Systems - CINTESISUniversidade do PortoPortoPortugal
  25. 25.Allergy UnitInstituto CUF Porto e Hospital CUF PortoPortoPortugal
  26. 26.Health Information and Decision Sciences Department - CIDES, Faculdade de MedicinaUniversidade do PortoPortoPortugal
  27. 27.Department of OtorhinolaryngologyAcademic Medical CentreAmsterdamThe Netherlands
  28. 28.Institute of Health Policy and Management IBMGErasmus UniversityRotterdamThe Netherlands
  29. 29.Skin and Allergy HospitalHelsinki University HospitalHelsinkiFinland
  30. 30.Federico II University Hospital Naples (R&D and DISMET)NaplesItaly
  31. 31.Allergology Department, Centre de l’Asthme et des Allergies, Hôpital d’Enfants Armand-Trousseau (APHP), Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d’Epidémiologie et de Santé Publique, Equipe EPARParisFrance
  32. 32.Institute of Social Medicine, Epidemiology and Health EconomicsCharité - Universitätsmedizin BerlinBerlinGermany
  33. 33.Institute for Clinical Epidemiology and BiometryUniversity of WuerzburgWürzburgGermany
  34. 34.Center for Rhinology and AllergologyWiesbadenGermany
  35. 35.Division of Internal Medicine, Asthma and AllergyBarlicki University Hospital, Medical University of LodzLodzPoland
  36. 36.Clínica de Alergia, Asma y PediatríaHospital Médica SurMexico CityMexico
  37. 37.Allergy and Clinical Immunology DepartmentHospital CUF-DescobertasLisbonPortugal
  38. 38.ENT Department, Hospital Clinic, Clinical and Experimental Respiratory Immunoallergy, IDIBAPS, CIBERESUniversitat de BarcelonaBarcelonaSpain
  39. 39.MedScript LtdDundalk, County LouthIreland
  40. 40.Section of Otolaryngology-Head and Neck Surgery, The University of Chicago Medical Center and The Pritzker School of MedicineThe University of ChicagoChicagoUSA
  41. 41.Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital and Central Clinical SchoolMonash UniversityMelbourneAustralia
  42. 42.Department of ImmunologyMonash UniversityMelbourneAustralia
  43. 43.Center for Pediatrics and Child Health, Institute of Human DevelopmentRoyal Manchester Children’s Hospital, University of ManchesterManchesterUK
  44. 44.Allergy Department, 2nd Pediatric ClinicAthens General Children’s Hospital “P&A Kyriakou”, University of AthensAthensGreece
  45. 45.Department of PediatricsNippon Medical SchoolTokyoJapan
  46. 46.Allergy Diagnostic and Clinical Research UnitUniversity of Cape Town Lung InstituteCape TownSouth Africa
  47. 47.Woodbrook Medical CentreLoughboroughUK
  48. 48.Allergy and Respiratory Research GroupThe University of EdinburghEdinburghUK
  49. 49.Department of Prevention of Environmental Hazards and AllergologyMedical University of WarsawWarsawPoland
  50. 50.Department of Clinical Epidemiology and BiostatisticsMcMaster UniversityHamiltonCanada
  51. 51.Allergy and Respiratory Research Group, Centre for Population Health SciencesThe University of Edinburgh Medical SchoolEdinburghUK
  52. 52.Department of Pediatrics and Child Health, Department of Immunology, Faculty of MedicineUniversity of ManitobaWinnipegCanada
  53. 53.Division of Allergy and Clinical ImmunologyUniversity of SalernoSalernoItaly
  54. 54.Centre of Pneumology, Faculty of MedicineUniversity of CoimbraCoimbraPortugal
  55. 55.Department of ENTMedical University of GrazGrazAustria
  56. 56.Clinic of Children’s Diseases, Faculty of MedicineVilnius UniversityVilniusLithuania
  57. 57.Public Health InstituteVilnius UniversityVilniusLithuania
  58. 58.European Academy of Paediatrics (EAP/UEMS-SP)BrusselsBelgium
  59. 59.Department of Lung Diseases and Clinical AllergologyUniversity of TurkuTurkuFinland
  60. 60.Allergy ClinicTerveystaloTurkuFinland
  61. 61.Unit of Geriatric ImmunoallergologyUniversity of Bari Medical SchoolBariItaly
  62. 62.Sachs’ Children and Youth Hospital, SödersjukhusetStockholmSweden
  63. 63.Institute of Environmental MedicineKarolinska InstitutetStockholmSweden
  64. 64.Queen’s UniversityBelfastNorthern Ireland, UK
  65. 65.Department of PulmonologyCelal Bayar UniversityManisaTurkey
  66. 66.Department of DermatologyMedical University of GrazGrazAustria
  67. 67.Swiss Institute of Allergy and Asthma Research (SIAF)University of ZurichDavosSwitzerland
  68. 68.Department of Allergy and ImmunologyHospital Quirón BizkaiaErandioSpain
  69. 69.Barcelona Institute for Global Health (ISGlobal)BarcelonaSpain
  70. 70.IMIM (Hospital del Mar Research Institute)BarcelonaSpain
  71. 71.CIBER Epidemiología y Salud Pública (CIBERESP)BarcelonaSpain
  72. 72.Universitat Pompeu Fabra (UPF)BarcelonaSpain
  73. 73.KyomedMontpellierFrance
  74. 74.Clinical Immunology and Allergy Unit, Department of Medicine SolnaKarolinska InstitutetStockholmSweden
  75. 75.Department of Pediatric Pulmonology and Allergy, Astrid Lindgren Children’s HospitalKarolinska University HospitalStockholmSweden
  76. 76.David Hide Asthma and Allergy Research CentreIsle of WightUK
  77. 77.Regionie Puglia, BariItaly
  78. 78.Faculdade de Medicina de LisboaPortuguese National Programme for Respiratory Diseases (PNDR)LisbonPortugal
  79. 79.Geriatric Unit, Department of Internal Medicine (DIBIMIS)University of PalermoPalermoItaly
  80. 80.Department of MedicineUniversity of Cape TownCape TownSouth Africa
  81. 81.Section of Respiratory Disease, Department of Oncology, Haematology and Respiratory DiseasesUniversity of Modena and Reggio EmiliaModenaItaly
  82. 82.Department of Respiratory Medicine, Academic Medical Center (AMC)University of AmsterdamAmsterdamThe Netherlands
  83. 83.Department of Respiratory MedicineNational Institute of Diseases of the Chest and HospitalDhakaBangladesh
  84. 84.Centre for Individualized Medicine, Department of Pediatrics, Faculty of MedicineLinköping UniversityLinköpingSweden
  85. 85.Department of Dermatology and AllergyRheinische Friedrich-Wilhelms-University BonnBonnGermany
  86. 86.Department of Respiratory Medicine and AllergologyUniversity HospitalLundSweden
  87. 87.Department of GeriatricsMontpellier University HospitalMontpellierFrance
  88. 88.EA 2991, EuromovUniversity MontpellierMontpellierFrance
  89. 89.Department of Pathophysiology and Transplantation, IRCCS Fondazione Ca’Granda Ospedale Maggiore PoliclinicoUniversity of MilanMilanItaly
  90. 90.Pediatric DepartmentUniversity of Verona HospitalVeronaItaly
  91. 91.Department of Public Health and Infectious DiseasesSapienza University of RomeRomeItaly
  92. 92.Second University of Naples and Institute of Translational MedicineItalian National Research CouncilNaplesItaly
  93. 93.La RochelleFrance
  94. 94.MontrealCanada
  95. 95.Quebec Heart and Lung InstituteLaval UniversityQuebec CityCanada
  96. 96.Health Economics and Health Technology Assessment, Institute of Health and WellbeingUniversity of GlasgowGlasgowUK
  97. 97.Institute of Lung Health, Respiratory Biomedical UnitUniversity Hospitals of Leicester NHS TrustLeicestershireUK
  98. 98.Department of Infection, Immunity and InflammationUniversity of LeicesterLeicesterUK
  99. 99.Universitätsmedizin der Johannes Gutenberg-Universität MainzMainzGermany
  100. 100.University of Medicine and Pharmacy Victor BabesTimisoaraRomania
  101. 101.Royal Brompton Hospital NHS, Imperial College LondonLondonUK
  102. 102.Centro Medico Docente La TrinidadCaracasVenezuela
  103. 103.National Heart and Lung Institute, Imperial College LondonLondonUK
  104. 104.MontpellierFrance
  105. 105.S. Allergologia, S. Medicina InternaHospital Vall d’HebronBarcelonaSpain
  106. 106.CEDOC, Respiratory Research GroupNova Medical SchoolLisbonPortugal
  107. 107.Serviço de ImunoalergologiaCentro Hospitalar de Lisboa Central, EPELisbonPortugal
  108. 108.Regional Ministry of Health of AndalusiaSevilleSpain
  109. 109.Department of PaediatricsOslo University HospitalOsloNorway
  110. 110.University of OsloOsloNorway
  111. 111.Allergy and Asthma Associates of Southern CaliforniaMission ViejoUSA
  112. 112.Allergy and Immunology LaboratoryMetropolitan University, Simon Bolivar UniversityBarranquillaColombia
  113. 113.SLaai, Sociedad Latinoamericana de Allergia, Asma e ImmunologiaCartagenaColombia
  114. 114.Gérontopôle de ToulouseToulouseFrance
  115. 115.Department of Social Medicine, Faculty of MedicineUniversity of CreteHeraklionGreece
  116. 116.School of MedicineUniversity CEU San PabloMadridSpain
  117. 117.Chachava Clinic, David Tvildiani Medical University-AIETI Medical SchoolGrigol Robakidze UniversityTbilisiGeorgia
  118. 118.Pulmonolory Research Institute FMBAMoscowRussia
  119. 119.GARD Executive CommitteeMoscowRussia
  120. 120.Medicine DepartmentIRCCS-Azienda Ospedaliera Universitaria San MartinoGenoaItaly
  121. 121.ICVS/3B’s-PT Government Associate Laboratory, Life and Health Sciences, Research Institute (ICVS), School of Health SciencesUniversity of MinhoBragaPortugal
  122. 122.Department of MedicineNova Southeastern UniversityDavieUSA
  123. 123.EIP on AHA, European Innovation Partnership on Active and Healthy Ageing, Reference SiteScottish Centre for Telehealth and Telecare, NHS 24GlasgowUK
  124. 124.Department of PediatricImperial College LondonLondonUK
  125. 125.The Centre for Allergy Research, The Institute of Environmental MedicineKarolinska InstitutetStockholmSweden
  126. 126.Department of Dermatology and AllergyTechnische Universität MünchenMunichGermany
  127. 127.ZAUM-Center for Allergy and Environment, Helmholtz Center MunichMunichGermany
  128. 128.AQuASBarcelonaSpain
  129. 129.EUREGHA, European Regional and Local Health AssociationBrusselsBelgium
  130. 130.Allergology and Immunology Discipline“Luliu Hatieganu” University of Medicine and PharmacyCluj-NapocaRomania
  131. 131.Division of Clinical Immunology and Allergy, Department of MedicineMcMaster UniversityHamiltonCanada
  132. 132.Peercode DVAmsterdamThe Netherlands
  133. 133.Respiratory Diseases DepartmentRangueil-Larrey HospitalToulouseFrance
  134. 134.Service de Physiologie Respiratoire, Hôpital CochinUniversité Paris-Descartes, Assistance Publique-Hôpitaux de ParisParisFrance
  135. 135.University Clinic of Pulmology and Allergy, Medical FacultySs Cyril and Methodius UniversitySkopjeRepublic of Macedonia
  136. 136.Service de Pneumo-AllergologieCentre Hospitalo-Universitaire de Béni-MessousAlgersAlgeria
  137. 137.Ecole des MinesAlèsFrance
  138. 138.Medical FacultyVilnius UniversityVilniusLithuania
  139. 139.Allergy and Clinical Immunology SectionNational Heart and Lung Institute, Imperial College LondonLondonUK
  140. 140.Guy’s and St Thomas’ NHS Trust, Kings College LondonLondonUK
  141. 141.Section of Allergy and ImmunologySaint Louis University School of MedicineSaint LouisUSA
  142. 142.Computing Science DepartmentUmeå UniversityUmeåSweden
  143. 143.Four Computing OyHalikkoFinland
  144. 144.Pediatric Allergy and Immunology UnitAin Shams UniversityCairoEgypt
  145. 145.Department of Health, Social Services and Public SafetyBelfastNorthern Ireland, UK
  146. 146.Global Allergy and Asthma Platform GAAPPViennaAustria
  147. 147.Division of Allergy, Department of Pediatric MedicineThe Bambino Gesù Children’s Research Hospital Holy SeeRomeItaly
  148. 148.Education for HealthWarwickUK
  149. 149.Department of Epidemiology, Regional Health Service Lazio RegionRomeItaly
  150. 150.Athens Chest HospitalAthensGreece
  151. 151.National Center for Disease Control and Public Health of GeorgiaTbilisiGeorgia
  152. 152.Department of Pulmonary Diseases, Cerrahpasa Faculty of MedicineIstanbul UniversityIstanbulTurkey
  153. 153.Allergy and Immunology DivisionClinica Ricardo PalmaLimaPeru
  154. 154.Section of Allergology, Department of Internal MedicineErasmus MCRotterdamThe Netherlands
  155. 155.Universidad Autónoma de Nuevo LeónSan Nicolás de los GarzaMexico
  156. 156.Center of Tuberculosis and Lung DiseasesLatvian Association of AllergistsRigaLatvia
  157. 157.Faculty of the Department of NeurologyUniversity of Washington School of MedicineSeattleUSA
  158. 158.National eHealth CentreUniversity Hospital OlomoucOlomoucCzech Republic
  159. 159.Immunology and Allergy Division Clinical HospitalUniversity of ChileSantiagoChile
  160. 160.Department of Respiratory DiseasesOdense University HospitalOdenseDenmark
  161. 161.Institute of Epidemiology IHelmholtz Zentrum München - German Research Center for Environmental HealthNeuherbergGermany
  162. 162.Vienna Challenge ChamberViennaAustria
  163. 163.Department of Paediatrics and Child HealthUniversity College CorkCorkIreland
  164. 164.Université Paris-SudLe Kremlin BicêtreFrance
  165. 165.Service de PneumologieHôpital BicêtreLe Kremlin BicêtreFrance
  166. 166.Inserm UMR_S999Le Kremlin BicêtreFrance
  167. 167.School of PsychologyPlymouth UniversityPlymouthUK
  168. 168.Department of Medicine and SurgeryUniversity of SalernoBaronissiItaly
  169. 169.Libra FoundationBuenos AiresArgentina
  170. 170.Airway Disease Infection Section, National Heart and Lung InstituteImperial College LondonLondonUK
  171. 171.MRC & Asthma UK Centre in Allergic Mechanisms of AsthmaLondonUK
  172. 172.Department of Respiratory MedicineGhent University HospitalGhentBelgium
  173. 173.Medical CommissionMontpellier University HospitalMontpellierFrance
  174. 174.Hallym University Sacred Heart HospitalHallym University College of MedicineAnyangSouth Korea
  175. 175.Department of Clinical ImmunologyWrocław Medical UniversityWrocławPoland
  176. 176.Ukrainian Medical Stomatological AcademyPoltavaUkraine
  177. 177.Laboratory of Molecular Immunology, National Research Center, Institute of ImmunologyFederal Medicobiological AgencyMoscowRussia
  178. 178.Pediatric Allergy and Asthma Unit, School of MedicineHacettepe UniversityAnkaraTurkey
  179. 179.Immunology and Allergy Division, Department of Chest Diseases, School of MedicineHacettepe UniversityAnkaraTurkey
  180. 180.First Department of Family MedicineMedical University of LodzLodzPoland
  181. 181.Department of MedicineMcMaster UniversityHamiltonCanada
  182. 182.Department of Pulmonary Diseases, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
  183. 183.GARDGenevaSwitzerland
  184. 184.Department of Respiratory Medicine, Faculty of Medicine and DentistryUniversity Hospital OlomoucOlomoucCzech Republic
  185. 185.Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children’s Hospital, GRIAC Research Institute, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
  186. 186.Department of Immunology, Rheumatology and Allergy and HARCMedical University of LodzLodzPoland
  187. 187.Children’s HospitalUniversity of HelsinkiHelsinkiFinland
  188. 188.Clinic of Infectious, Chest Diseases, Dermatology and AllergologyVilnius UniversityVilniusLithuania
  189. 189.VIB Inflammation Research CenterGhent UniversityGhentBelgium
  190. 190.Department for Pediatric Pneumology and ImmunologyCharité Medical UniversityBerlinGermany
  191. 191.University of Medicine and PharmacyHochiminh CityVietnam
  192. 192.Divisions of Allergy and Immunology, Department of Internal Medicine and PediatricsUniversity of Tennessee College of MedicineGermantownUSA
  193. 193.Scottish Centre for Respiratory Research, Cardiovascular and Diabetes Medicine, Medical Research Institute, Ninewells HospitalUniversity of DundeeDundeeUK
  194. 194.State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory DiseaseThe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
  195. 195.Institute of Clinical Medicine, Faculty of MedicineUniversity of OsloOsloNorway
  196. 196.Department of Pulmonary MedicineCHU Sart-TilmanLiegeBelgium
  197. 197.Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and ImmunologyMedical University of ViennaViennaAustria
  198. 198.The Queen’s Medical Research InstituteUniversity of EdinburghEdinburghUK
  199. 199.Service de Pneumo-allergologieHôpital Saint-JosephParisFrance
  200. 200.Service de Pneumologie, UMR INSERM, UMR1087 and CNR 6291, l’institut du ThoraxUniversity of NantesNantesFrance
  201. 201.Department of Pulmonary MedicineRashid HospitalDubaiUAE
  202. 202.Biomax Informatics AGMunichGermany
  203. 203.Department of Respiratory MedicineUniversity of BratislavaBratislavaSlovakia
  204. 204.Institute of Biomedical Imaging and Life Sciences (IBILI), Faculty of MedicineUniversity of CoimbraCoimbraPortugal
  205. 205.Ageing@Coimbra EIP-AHA Reference SiteCoimbraPortugal
  206. 206.Department of Medicine (RCSI)Bon Secours HospitalGlasnevin, DublinIreland
  207. 207.KronikguneBasque RegionSpain
  208. 208.Laboratory of Behavioral Immunology Research, Division of Clinical Immunology and AllergyThe University of Mississippi Medical CenterJacksonUSA
  209. 209.Tobacco Control Research CentreIranian Anti Tobacco AssociationTehranIran
  210. 210.Department of PaediatricsMaputo Central HospitalMaputoMozambique
  211. 211.Allergy and Asthma Medical Group and Research CenterSan DiegoUSA
  212. 212.Department of Physiology, CHRU, PhyMedExp, INSERM U1046, CNRS UMR 9214University MontpellierMontpellierFrance
  213. 213.Hautklinik - Klinik für Dermatologie & AllergologieUniversitätsklinikum der RWTH AachenAachenGermany
  214. 214.Croatian Pulmonary SocietyZagrebCroatia
  215. 215.National Institute of Pneumology M. NastaBucharestRomania
  216. 216.Faculty of MedicineUniversity of BelgradeBelgradeSerbia
  217. 217.Serbian Association for Asthma and COPDBelgradeSerbia
  218. 218.Caisse d’assurance retraite et de la santé au travail du Languedoc-Roussillon (CARSAT-LR)MontpellierFrance
  219. 219.National Center for Research in Chronic Respiratory DiseasesTishreen University School of MedicineLatakiaSyria
  220. 220.Department of Public Health and Health Products, EA 4064Paris Descartes University-Sorbonne Paris CitéParisFrance
  221. 221.Paris Municipal Department of Social Action, Childhood, and HealthParisFrance
  222. 222.Institute of Medical Statistics, Informatics and Epidemiology, Medical FacultyUniversity of CologneCologneGermany
  223. 223.Food Allergy Referral Centre Veneto Region, Department of Women and Child HealthPadua General University HospitalPaduaItaly
  224. 224.Scientific Centre of Children’s Health Under the Russian Academy of Medical SciencesMoscowRussia
  225. 225.Hospital de Niños Orlando AlassiaSanta FeArgentina
  226. 226.Hospital of the Hospitaller Brothers in BudaBudapestHungary
  227. 227.Neumología y Alergología InfantilHospital La FeValenciaSpain
  228. 228.Department of Internal MedicineCentro Hospitalar Sao JoaoPortoPortugal
  229. 229.ENT DepartmentUniversity Hospital of KinshasaKinshasaCongo
  230. 230.National Hospital OrganizationTokyo National HospitalTokyoJapan
  231. 231.Department of OtorhinolaryngologyChiba University HospitalChibaJapan
  232. 232.Department of OtolaryngologyNippon Medical SchoolTokyoJapan
  233. 233.Centre Hospitalier Universitaire Pédiatrique Charles de GaulleOuagadougouBurkina Faso
  234. 234.Cardio-Thoracic and Vascular DepartmentUniversity Hospital of PisaPisaItaly
  235. 235.Department of Comparative MedicineMesserli Research Institute of the University of Veterinary Medicine, Medical UniversityViennaAustria
  236. 236.Department of Immunology and Allergology, Faculty of Medicine and Faculty Hospital in PilsenCharles University in PraguePilsenCzech Republic
  237. 237.Respiratory Medicine, Department of Medical SciencesUniversity of FerraraFerraraItaly
  238. 238.Department of Allergy and Clinical ImmunologyAjou University School of MedicineSuwonSouth Korea
  239. 239.University of Southern DenmarkKoldingDenmark
  240. 240.Allergy Unit, CUF-Porto Hospital and InstitutePortoPortugal
  241. 241.Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty MannheimHeidelberg UniversityMannheimGermany
  242. 242.Conseil Général de l’Economie, Ministère de l’Economie, de l’Industrie et du NumériqueParisFrance
  243. 243.Société de Pneumologie de Langue FrançaiseEspace francophone de PneumologieParisFrance
  244. 244.Département de pédiatrieCHU de GrenobleGrenobleFrance
  245. 245.Children’s Hospital SrebrnjakZagrebCroatia
  246. 246.School of MedicineUniversity J.J. StrossmayerOsijekCroatia
  247. 247.Karl Landsteiner Institute for Clinical and Experimental PneumologyHietzing HospitalViennaAustria
  248. 248.Clinic of Allergy and AsthmaMedical University SofiaSofiaBulgaria
  249. 249.University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
  250. 250.Laboratory of Medical Allergology, Allergy ClinicCopenhagen University Hospital at GentofteCopenhagenDenmark
  251. 251.Academic Centre of Primary CareUniversity of AberdeenAberdeenScotland, UK
  252. 252.Research in Real-LifeCambridgeUK
  253. 253.LungenClinic Grosshansdorf, Airway Research Center North, German Center for Lung Research (DZL)GrosshansdorfGermany
  254. 254.Department of MedicineChristian Albrechts University, Airway Research Center North, German Center for Lung Research (DZL)KielGermany
  255. 255.NHS Foundation TrustUniversity Hospitals of SouthamptonSouthamptonUK
  256. 256.Centre of PneumologyCoimbra University HospitalCoimbraPortugal
  257. 257.Polibienestar Research InstituteUniversity of ValenciaValenciaSpain
  258. 258.Department of GeriatricsGetafe University HospitalMadridSpain
  259. 259.Association Asthme et AllergieParisFrance
  260. 260.Primary Care Respiratory Research UnitInstitutode Investigación Sanitaria de Palma IdisPaPalma de MallorcaSpain
  261. 261.Allergy UnitComplesso Integrato ColumbusRomeItaly
  262. 262.Serviço de ImunoalergologiaHospital da LuzLisbonPortugal
  263. 263.Hospital de ClinicasUniversity of ParanaCuritibaBrazil
  264. 264.Division of Allergy Asthma and Clinical ImmunologyEmek Medical CenterAfulaIsrael
  265. 265.Allergy and Clinical Immunology DepartmentCentro Médico-Docente La Trinidad and Clínica El AvilaCaracasVenezuela
  266. 266.Faculty of MedicineAutononous University of MadridMadridSpain
  267. 267.The Royal National TNE HospitalUniversity College LondonLondonUK
  268. 268.DIBIMISUniversity of PalermoPalermoItaly
  269. 269.Allergy Unit, Department of DermatologyUniversity Hospital of ZurichZurichSwitzerland
  270. 270.Otolaryngology and Head and Neck SurgeryCHU Rangueil-LarreyToulouseFrance
  271. 271.Child HealthQueen’s UniversityBelfastNorthern Ireland, UK
  272. 272.Royal Belfast Hospital for Sick ChildrenBelfastNorthern Ireland, UK
  273. 273.INSERM, Université Grenoble Alpes, IAB, U 1209, Team of Environmental Epidemiology Applied to Reproduction and Respiratory HealthUniversité Joseph FourierGrenobleFrance
  274. 274.Sociedad Paraguaya de Alergia Asma e InmunologıaAsunciónParaguay
  275. 275.Julius Center of Health Sciences and Primary Care, University Medical Center UtrechtUniversity of UtrechtUtrechtThe Netherlands
  276. 276.Division of Allergy, Clinical Immunology and Rheumatology, Department of PediatricsFederal University of São PauloSão PauloBrazil
  277. 277.Kyrgyzstan National Centre of Cardiology and Internal MedicineEuro-Asian Respiratory SocietyBishkekKyrgyzstan
  278. 278.Pulmonary Division, Heart Institute (InCor)Hospital da Clinicas da Faculdade de Medicina da Universidade de Sao PauloSão PauloBrazil
  279. 279.Academic Medical CentreUniversity of AmsterdamAmsterdamThe Netherlands
  280. 280.European Union Geriatric Medicine Society (EUGMS)HelsinkiFinland
  281. 281.Department of Epidemiology, CAPHRI School of Public Health and Primary CareMaastricht UniversityMaastrichtThe Netherlands
  282. 282.Pneumology and Allergy DepartmentHospital Clínic, Clinical and Experimental Respiratory Immunoallergy, IDIBAPSBarcelonaSpain
  283. 283.PELyonLyonFrance
  284. 284.HESPER 7425, Health Services and Performance ResarchUniversité Claude Bernard LyonVilleurbanneFrance
  285. 285.University HospitalStockholmSweden
  286. 286.Department of Chest Medicine, Centre Hospitalier Universitaire UCL NamurUniversité Catholique de LouvainYvoirBelgium
  287. 287.Philippines Society of Allergy, Asthma and ImmunologyManilaPhilippines
  288. 288.Pulmonary Unit, Department of Cardiology, Thoracic and Vascular MedicineArcispedale S. Maria Nuova/IRCCS, Research HospitalReggio EmiliaItaly
  289. 289.Regional Agency for Health and Social CareReggio EmiliaItaly
  290. 290.Finnish Lung Association (FILHA)HelsinkiFinland
  291. 291.Pulmonary Environmental Epidemiology UnitCNR Institute of Clinical PhysiologyPisaItaly
  292. 292.CNR Institute of Biomedicine and Molecular Immunology “A. Monroy”PalermoItaly
  293. 293.Sotiria HospitalAthensGreece
  294. 294.Department of Otorhinolaryngology, HNO-KlinikUniversitätsklinikum DüsseldorfDüsseldorfGermany
  295. 295.Asthma UKLondonUK
  296. 296.Department of Otolaryngology, Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
  297. 297.Division of Immunodermatology and Allergy Research, Department of Dermatology and AllergyHannover Medical SchoolHannoverGermany
  298. 298.Eshelman School of PharmacyUniversity of North CarolinaChapel HillUSA
  299. 299.IPCRGAberdeenScotland, UK
  300. 300.Bradford Institute for Health Research, Bradford Royal InfirmaryBradfordUK
  301. 301.Department of ResearchOlmsted Medical CenterRochesterUSA
  302. 302.Medical SchoolUniversity of CyprusNicosiaCyprus
  303. 303.The Allergy and Asthma InstituteLahorePakistan
  304. 304.Social SciencesUniversity of SouthamptonSouthamptonUK
  305. 305.Department of Paediatrics and Child HealthRed Cross Children’s Hospital, University of Cape TownCape TownSouth Africa
  306. 306.MRC Unit on Child and Adolescent HealthUniversity of Cape TownCape TownSouth Africa
  307. 307.Universidad Católica de CórdobaCórdobaArgentina
  308. 308.Department of Otolaryngology Head and Neck SurgeryBeijing TongRen HospitalBeijingChina
  309. 309.Beijing Institute of OtolaryngologyBeijingChina
  310. 310.University Clinic of Respiratory and Allergic DiseasesGolnikSlovenia
  311. 311.Northern Health AllianceNewcastleUK
  312. 312.CHRU Arnaud de VilleneuveMontpellier Cedex 5France

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