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Original Article
Mould and grass pollen allergy as risk factors for childhood asthma in Zaragoza, Spain
N. Seguraa,b,
Corresponding author
nseguraa@gmail.com

Corresponding author.
, J. Fraja,b, J.L. Cuberoa,b, M.T. Sobrevíaa,b, A. Lezauna,b, L. Ferrera,b, A. Sebastiánc,b, C. Colása,b
a Allergy Department, University Hospital Lozano Blesa of Zaragoza, Avda. San Juan Bosco, 15, 50009 Zaragoza, Spain
b Aragon Health Research Institute (IIS Aragón), Centro de Investigación Biomédica de Aragón (CIBA), Avda. San Juan Bosco, 13, 50009 Zaragoza, Spain
c Pneumology Department, University Hospital Lozano Blesa of Zaragoza, Avda. San Juan Bosco, 15, 50009 Zaragoza, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Asthma is a multifactorial disease with a high prevalence in childhood&#46; It involves a significant degree of morbidity&#44; loss of quality of life for the child and parents and great cost&#44; direct and indirect&#44; to the family and Health Administration&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;2</span></a> In Spain&#44; following the epidemiological questionnaire of the International Study of Asthma and Allergy in Children &#40;ISAAC&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> the prevalence of childhood asthma was studied in Huesca&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> Castell&#243;n<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> and all participating areas&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> The later study included 42&#44;417 Spanish children in phase I &#40;1994&#8211;1995&#41;&#44; and 42&#44;813 in phase III &#40;2002&#8211;2003&#41;&#46; The prevalence of asthma in children aged 6&#8211;7 years&#44; reported by parents&#44; was 7&#37; and 10&#46;7&#37; for boys in phases I and III and 5&#46;3&#37; and 8&#46;2&#37; for girls in phases I and III&#44; respectively&#46; The self-reported prevalence of asthma in adolescents aged 13&#8211;14 years was 9&#37; and 9&#46;3&#37; in boys&#44; in phases I and III&#44; and 9&#46;6&#37; and 9&#46;2&#37; in girls in phases I and III&#44; respectively&#46; However&#44; the results on the prevalence of asthma in many Western countries&#44; even within the same country&#44; are not always comparable&#44; given the geographical&#44; cultural and socioeconomic differences that produce wide variations in the frequency of this disease&#44; nationally and internationally&#46; These differences<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> would probably be due to environmental factors &#40;level of hygiene&#44; allergenic pressure&#44; infections&#44; overuse of antibiotics and other unknown factors&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Following the same ISAAC epidemiological questionnaire&#44; the aim of this study was to estimate the prevalence of asthma and its associated predictors in a school population of the city of Zaragoza&#44; Spain&#46; It is named the LAPIZ study &#40;<span class="elsevierStyleItalic">Estudio epidemi<span class="elsevierStyleBold">L</span>&#243;gico de <span class="elsevierStyleBold">A</span>sma en <span class="elsevierStyleBold">P</span>oblaci&#243;n <span class="elsevierStyleBold">I</span>nfantil de <span class="elsevierStyleBold">Z</span>aragoz</span>a &#91;Epidemiological Study of Asthma in the Juvenile Population of Zaragoza&#93;&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Patients and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">The design was a descriptive&#44; cross-sectional&#44; observational study of a representative population of 468 children aged 10&#8211;12 years in the city of Zaragoza&#46; The study was approved by the local health authority &#40;Instituto Aragon&#233;s de Ciencias de la Salud &#8211; IACS&#41; and its Ethics Committee&#46; Children of this age were chosen for their comprehension and ability to self-complete the questionnaire&#44; which is not possible for younger children&#44; and for being the oldest group that had afternoon classes once our business hours were over&#46; In the random sampling 14 schools were included&#44; public or semi-private&#44; and one private&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The required sample size calculation was 457 children&#44; making a rough estimate of the population group of 10&#8211;12 years of 11&#44;219 people &#40;based on official figures from the current census during the design of the study that showed 28&#44;047 children aged 10&#8211;14 years&#41;&#44; for a confidence level of 95&#37;&#44; accuracy of 2&#37; and prevalence of childhood asthma of 5&#37;&#46; The sample represented different areas of the city and took place during the autumn and winter months of the 2007&#8211;2008 school academic year&#46; We excluded spring and summer because hypersensitivity to grass pollen&#44; olive and <span class="elsevierStyleItalic">Chenopodiaceae</span>&#44; which pollinate during those months&#44; is the most relevant in our geographic area&#46; We thus avoided children receiving symptomatic treatment at the time of the study&#44; which could bias the results&#46; The study only included children whose parents had signed the informed consent&#46; Non-participants were sent an anonymous and voluntary survey asking why they had decided not to participate&#58; forgetfulness&#59; being already diagnosed with asthma and&#47;or allergy&#59; the child does not have any health problems&#59; the child did not want to participate&#59; the parents have not received the informed consent to sign&#59; other causes&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">At the outset&#44; the children self-completed the validated ISAAC questionnaire<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> for asthma and allergy under the investigators&#8217; supervision&#46; We chose this questionnaire for validation due to its great relevance worldwide&#46; Self-completion yielded two groups&#58; those who had no symptoms suggestive of asthma and those who&#44; in the last 12 months&#44; had experienced asthmatic symptoms and&#47;or had been diagnosed with asthma&#46; Risk factors for asthma assessed in the questionnaire<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> were genetic risk &#40;family history of asthma&#41; and environmental risk &#40;exposure to tobacco smoke&#44; domestic animals and relevant respiratory illness&#41;&#46; The risk for atopy was assessed by testing the presence of immediate hypersensitivity through skin prick test to one of the most significant environmental aeroallergens in our environment &#40;Bial-Ar&#237;stegui&#44; Bilbao&#44; Spain&#41;&#44; including <span class="elsevierStyleItalic">Phleum pratense</span>&#44; <span class="elsevierStyleItalic">Olea europaea</span>&#44; <span class="elsevierStyleItalic">Salsola kali</span>&#44; <span class="elsevierStyleItalic">Parietaria judaica</span>&#44; <span class="elsevierStyleItalic">Platanus acerifolia</span>&#44; <span class="elsevierStyleItalic">Cupressus sempervirens</span>&#44; <span class="elsevierStyleItalic">Dermatophagoides</span> spp&#46;&#44; <span class="elsevierStyleItalic">Alternaria alternata</span> and dog and cat dander&#46; Histamine hydrochloride &#40;10<span class="elsevierStyleHsp" style=""></span>mg&#47;mL&#41; and glycerol saline served as positive and negative controls respectively&#46; A skin test was considered positive when its wheal diameter was larger &#8805;3<span class="elsevierStyleHsp" style=""></span>mm than the negative control&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Statistical analysis</span><p id="par0030" class="elsevierStylePara elsevierViewall">SPSS &#40;version 15&#41; was used to conduct the statistical analysis&#46; Quantitative variables were expressed by their mean and standard deviation and qualitative variables as proportions&#46; Relationships between paired variables were analysed using contingency tables and Pearson contrasts <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> for qualitative variables&#46; In the case of a qualitative and quantitative variable&#44; relationships were analysed by Student <span class="elsevierStyleItalic">t</span>-test for comparison of means&#46; Finally&#44; multivariate logistic regression was used to identify factors predicting asthma&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">Of an initial sample of 848 children&#44; 468 participated in our study&#44; representing 55&#37;&#46; The demographic characteristics of non-participants did not differ from the sample&#58; the schools and homes of the children were in the same metropolitan area with similar air pollution and they were studying the same academic year&#46; The anonymous and voluntary survey sent to non-participants was returned by 211 parents &#40;55&#46;53&#37;&#41; and the reasons given were&#58; forgetfulness 6&#46;16&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#41;&#59; being already diagnosed with asthma and&#47;or allergy 12&#46;79&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>27&#41;&#59; the child does not have any health problems 33&#46;17&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>70&#41;&#59; the child did not want to participate 18&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>38&#41;&#59; the parents have not received the informed consent to sign 2&#46;84&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41;&#44; and other causes 27&#46;01&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>57&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the general characteristics of the study population&#46; According to the results of the ISAAC questionnaire&#44; 118 of 466 children had symptoms consistent with asthma&#44; those classified as possible asthmatic representing 25&#46;3&#37;&#46; They are children who answered yes to one or both of two questions&#58; &#8220;Have you had wheezing or whistling in the chest in the last 12 months&#63;&#8221; and&#44; &#8220;Have you ever had asthma&#63;&#8221; The estimated prevalence of asthma&#44; according to responses to the first question&#44; was 15&#46;8&#37;&#46; An affirmative answer to the second question equates with diagnosed asthma and involves a previous diagnosis by a doctor&#46; In this case the estimated prevalence of asthma was 16&#46;8&#37;&#46; This percentage is similar to that obtained when asked if they had ever presented wheezing or whistling in the chest in the last 12 months&#46; There were no significant differences in gender distribution&#46; Thirty-three point one percent &#40;33&#46;1&#37;&#41; of asthmatic children answered yes to the question&#44; &#8220;Is there a history of asthma in the immediate family&#63;&#8221;&#44; which is statistically significant &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;78&#44; 95&#37; CI 1&#46;05&#8211;3&#46;01&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; A relevant number of asthmatics are assumed to be exposed routinely to tobacco smoke at home&#44; with fathers more likely to be smokers than mothers &#40;39&#37;&#41;&#44; but only maternal smoking was slightly associated with the presence of asthma &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;044&#41;&#46; The tendency in developed countries to have pets in the homes is confirmed in our series in which we observed that 52&#37; of the total sample of children surveyed had animals at home&#44; the dog being the most common&#44; followed by cat&#44; hamster and parakeet&#46; Within the group of asthmatic children&#44; 52&#46;5&#37; had a pet&#46; However&#44; living with pets showed no statistical significance&#46; Finally&#44; when asked for a prior history of hospitalisations due to lower respiratory illness&#44; 22&#37; of children with asthma responded positively &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#46;72&#44; 95&#37; CI 3&#46;08&#8211;14&#46;70&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The results of the skin tests in the total sample appear in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; As expected&#44; hypersensitivity to grass pollen was the most frequent &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>108&#44; 23&#46;2&#37;&#41;&#44; followed by hypersensitivity to olive pollen &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>83&#44; 17&#46;8&#37;&#41;&#44; aerogenic fungus <span class="elsevierStyleItalic">Alternaria</span> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>69&#44; 14&#46;8&#37;&#41;&#44; <span class="elsevierStyleItalic">Salsola</span> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>60&#44; 12&#46;9&#37;&#41; and cat dander &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>48&#44; 10&#46;3&#37;&#41;&#46; Hypersensitivity to mites&#44; plane tree pollen&#44; <span class="elsevierStyleItalic">Parietaria</span> and dog dander was less relevant&#46; Skin tests that were most frequently positive in asthmatic children were the same as in the total sample&#46; Thirty-four percent &#40;34&#37;&#41; showed hypersensitivity to grass pollen and 26&#37; to olive pollen and <span class="elsevierStyleItalic">Alternaria</span>&#44; equally&#46; Skin tests positive for grass&#44; olive&#44; <span class="elsevierStyleItalic">Alternaria</span>&#44; cypress and mites were present in asthmatic children at a rate higher than that observed in non-asthmatics&#44; resulting in statistically significant data &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Positive skin tests to <span class="elsevierStyleItalic">Alternaria</span> &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;00&#44; 95&#37; CI 1&#46;07&#8211;3&#46;75&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; and grass pollen &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;76&#44; 95&#37; CI 1&#46;02&#8211;3&#46;01&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; were predictors of asthma&#46; Overall&#44; children with asthma had more frequent positive skin tests to aeroallergens&#44; both in terms of a single test and two or more positive tests &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;08&#44; 95&#37; CI 1&#46;30&#8211;3&#46;40&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">More than half of the children &#40;52&#46;4&#37;&#41; answered &#8220;yes&#8221; to the question whether&#44; at some time&#44; they had suffered symptoms of rhinitis&#44; without it coinciding with a cold&#46; When asked specifically whether they had had symptoms of rhinitis in the past year&#44; the number of children who responded affirmatively dropped to 39&#46;7&#37;&#46; To another question&#44; considered especially relevant &#40;Have you ever had hay fever&#47;rhinitis&#47;allergic conjunctivitis&#63;&#41;&#44; 17&#46;8&#37; responded affirmatively&#46; Sixty-three point six percent &#40;63&#46;6&#37;&#41; of asthmatic children presented symptoms of rhinitis in the last 12 months&#44; compared to 31&#46;9&#37; of non-asthmatics&#44; and this difference was statistically significant &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;77&#44; 95&#37; CI 2&#46;30&#8211;6&#46;18&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Ninety children &#40;19&#46;2&#37;&#41; of the total sample said they had occasionally suffered an itchy rash compatible with atopic eczema&#46; When asked if it had occurred in the past year&#44; the number decreased to 52 &#40;11&#46;1&#37;&#41;&#46; With respect to the relationship between the presence of asthma and eczema&#44; 47&#37; of asthmatics had or had previously presented eczema lesions&#44; whereas only 26&#46;9&#37; of non-asthmatics had or had previously presented these lesions&#44; resulting in a significant difference &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Multivariate logistic regression results are shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Fifteen point eight percent &#40;15&#46;8&#37;&#41; of the children reported wheezing in the last 12 months&#46; When we assessed children diagnosed with asthma&#44; meaning diagnosed by a doctor&#44; the percentage was similar&#58; 16&#46;8&#37;&#46; The values are higher than would be expected initially&#44; when compared with those obtained by the ISAAC study in Spain by Garc&#237;a-Marcos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> but lower than Carvajal-Urue&#241;a et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a> on Spain&#39;s northern Atlantic coast&#46; The high prevalence of children with symptoms compatible with asthma in our study is likely due to our including non-asthmatic children within the group of asthmatics&#46; This is one of the limitations of this type of questionnaire&#46; Like the ISAAC study questionnaire&#44; it allows us to make comparisons between different clinical settings and geographic areas&#44; using the same methodology&#46; We must bear in mind&#44; however&#44; that the purpose of these questionnaires is to conduct an epidemiological study and not to formulate a clinical diagnosis&#46; Other limitations of our study are that the cross-sectional design limits the assessment of risk factors&#44; the low participation&#44; the lack of objective measures of asthma&#44; and the absence of some other risk factors for asthma &#40;social class&#44; truck traffic&#44; maternal age&#44; etc&#46;&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In our study there were no significant differences in gender distribution&#46; Arnedo-Pena et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> demonstrate that male gender is a risk factor for asthma&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">A family history of asthma is very relevant in asthmatic patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">12&#44;13</span></a> This is also reflected in our results&#44; in which we see a significant association between asthma symptoms and a family history of asthma&#59; the presence of close relatives with asthma would be a predictor of the disease&#46; Consequently&#44; early diagnosis is desirable in children with a close family history of symptoms suggestive of asthma&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Smoking is the leading cause of preventable disease in the developed world&#46; We know that inhaling tobacco smoke&#44; both active and passive&#44; can cause asthma exacerbations&#46; Some authors even point to tobacco smoke not only to cause exacerbations but also as a direct inducer&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">14&#44;15</span></a> Arnedo-Pena et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> demonstrates that the father smoking at home is a risk factor for asthma&#46; Our epidemiological study found that maternal smoking&#44; but not the father&#39;s&#44; was significantly associated with the presence of asthma&#46; This can easily be explained&#58; the mother is with the child far more hours than the child&#39;s father&#46; Unfortunately&#44; smoking has increased significantly among women in recent decades&#44; becoming a relevant and completely avoidable risk factor&#46; Hence it is important to continue to promote anti-smoking campaigns&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Many epidemiological studies have attempted to assess the possible correlation between pet exposure and the prevalence of asthma and other allergic diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">16&#44;17</span></a> In recent years there have been studies that cast doubt on the influence of exposure to these animals as inducing IgE-mediated sensitisation&#46; For Almqvist et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> the coexistence of children with certain pets in the early stages of life would not increase the risk of asthma&#46; Arnedo-Pena et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> demonstrates that the presence of a dog at home is a risk factor for asthma&#46; In our series&#44; we found no significant relationship between the presence of asthma and exposure to dog&#44; cat or another pet&#46; Much more striking was the correlation between the presence of asthma and a history of hospitalisations for respiratory illness&#46; For years we have known that infant bronchiolitis may act as a factor inducing asthma&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11&#44;19&#44;20</span></a> Although the questionnaire does not explore the infectious disease that caused the hospitalisation&#44; presumably in many cases it would be bronchiolitis or another severe respiratory infection&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">More than half of the children with asthma showed positive allergy skin tests&#46; The positivity to a single allergen&#44; two allergens&#44; or more than two allergens was significantly higher in asthmatic children than in those who were not&#46; The highest percentage of positive skin tests&#44; both in the total study population as well as in asthmatic children&#44; was to grass pollen&#44; followed by olive and <span class="elsevierStyleItalic">Alternaria</span>&#44; consistent with the geographical and climatic characteristics of the middle Ebro valley&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> Deserving special mention is sensitisation to <span class="elsevierStyleItalic">Alternaria</span>&#44; especially significant in children and adolescents with asthma&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">22&#44;23</span></a> In our series it appears as the third most frequent sensitisation&#44; to the point that 26&#37; of asthmatic children showed positive prick test to this fungus&#46; In many cases this sensitisation is associated with more severe forms of asthma and worse outcomes&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> so that&#44; for some authors&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> sensitisation and exposure to <span class="elsevierStyleItalic">Alternaria alternata</span> is a clear predisposing factor for severe exacerbation in children&#44; adolescents and young adults with asthma&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The current scientific community sees rhinitis and asthma as a single disease<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">26&#44;27</span></a> that affects the different levels of the airway&#46; Hence&#44; from a clinical&#44; pathophysiological and epidemiological standpoint&#44; they are closely interrelated&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> In our study&#44; 63&#46;6&#37; of asthmatic children had shown symptoms of rhinitis in the last 12 months&#44; compared to 31&#46;9&#37; of non-asthmatics&#44; representing a significant difference&#46; It is well known that the presence of rhinitis is a risk factor associated with the incidence of asthma&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11&#44;29</span></a> a fact confirmed in our study&#46; In parallel&#44; 47&#37; of asthmatic children presented or had presented eczema occasionally versus 26&#46;9&#37; of non-asthmatics&#44; an equally significant finding&#46; Therefore&#44; in accordance with the general acceptance&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> the presence of eczema in our children population was associated with the prevalence of asthma&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In conclusion&#44; we believe that&#44; in relation to the questionnaire responses&#44; between 15&#46;8&#37; and 25&#46;3&#37; of children had symptoms consistent with asthma in the city of Zaragoza&#46; The history of hospital admissions for lower respiratory tract illness&#44; the presence of rhinitis and&#47;or eczema&#44; the prick test positive to certain aeroallergens&#44; especially <span class="elsevierStyleItalic">Alternaria</span>&#44; family history of asthma and maternal smoking are risk factors associated with the development of asthma&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Ethical disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Confidentiality of data</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Right to privacy and informed consent</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Protection of human subjects and animals in research</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Funding</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleGrantSponsor" id="gs1">Aragonese Foundation for Research Development in Allergology &#40;FADIA&#41;</span>&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">None of the authors has a financial relationship with a commercial entity that has an interest in the subject of this manuscript&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Examine the prevalence of asthma and associated predictive factors in a group of 468 students&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A descriptive&#44; cross-sectional observational study in a randomly selected population of 468 children aged 10&#8211;12&#44; in the city of Zaragoza&#46; We used the ISAAC questionnaire on asthma completed by children under supervision of the investigators&#46; We assessed the genetic risk &#40;family history of asthma&#41; and environmental risks&#46; The risk for atopy was assessed by the presence of positive skin prick tests&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">25&#46;3&#37; of the children had symptoms consistent with asthma in the city of Zaragoza&#46; Among them 33&#46;1&#37; reported a history of asthma in close relatives &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;78&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The history of hospitalisations for lower respiratory tract illness was strongly associated with the presence of asthma &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#46;72&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; Positive skin tests to <span class="elsevierStyleItalic">Alternaria</span> &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;00&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; and grass pollen &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;76&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; were predictors of asthma&#46; 63&#46;6&#37; of asthmatic children had presented clinical rhinitis in the previous 12 months&#44; compared with 32&#37; of non-asthmatics&#44; and this difference was statistically significant &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;89&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; 47&#37; of asthmatics presented with or previously had eczema&#44; whereas only 26&#46;9&#37; of non-asthmatics presented with or previously had these types of lesions &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The following are predictors of asthma&#58; History of hospital admissions for lower respiratory tract illness&#44; presence of rhinitis and&#47;or eczema&#44; positive prick test for certain aeroallergens&#44; especially <span class="elsevierStyleItalic">Alternaria</span> and grass pollen&#44; and family history of asthma&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
      ]
    ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Relationship between the presence of eczema and rhinitis in asthmatic and non-asthmatic group&#46;</p>"
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          0 => array:3 [
            "identificador" => "at1"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Percentage &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Sex</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">246&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">222&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Age &#40;years&#41;</span><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">393&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              ]
              "imagenFichero" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Characteristics of participating student population&#46;</p>"
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        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
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          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">ns&#44; not significant&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wheezing at any time &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>468&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100 &#40;21&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">368 &#40;78&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wheezing in the past 12 months &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>468&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74 &#40;15&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">394 &#40;84&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asthma at any time &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>465&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78 &#40;16&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">387 &#40;83&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wheezing during exercise &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>468&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">115 &#40;24&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">353 &#40;75&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dry cough &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>468&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">147 &#40;31&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">321 &#40;68&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Family history of asthma &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>468&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101 &#40;21&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">367 &#40;78&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Exposure to maternal tobacco smoke &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>466&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">147 &#40;31&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">319 &#40;68&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;044&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dog at home &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>468&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101 &#40;21&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">367 &#40;78&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cat at home &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>468&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51 &#40;10&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">417 &#40;89&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other animal at home &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>468&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92 &#40;19&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">376 &#40;80&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Visits&#47;hospital admissions for respiratory illness &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>468&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39 &#40;8&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">429 &#40;91&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Prevalence of asthma symptoms and associated risk factors&#46;</p>"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">ns&#44; not significant&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Allergen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">No asthma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Asthma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Total sample&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>350&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>118&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Grass&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;006&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Salsola</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cat&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cypress&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mites&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Plane tree&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Parietaria</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;729 &#40;3&#46;081&#8211;14&#46;696&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;085 &#40;1&#46;302&#8211;3&#46;339&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;771 &#40;2&#46;302&#8211;6&#46;176&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;081&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;798 &#40;1&#46;062&#8211;3&#46;046&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Symptoms of rhinitis in the last 12 months&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;891 &#40;2&#46;374&#8211;6&#46;378&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;031&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;000 &#40;1&#46;067&#8211;3&#46;750&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;041&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;085&nbsp;\t\t\t\t\t\t\n
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              "identificador" => "bib0155"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Out-of-pocket medication costs and use of medications and health care services among children with asthma"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "P&#46; Karaca-Mandia"
                            1 => "A&#46;B&#46; Jena"
                            2 => "G&#46;F&#46; Joyce"
                            3 => "D&#46;P&#46; Goldman"
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                    0 => array:2 [
                      "doi" => "10.1001/jama.2012.340"
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                        "volumen" => "307"
                        "paginaInicial" => "1284"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22453569"
                            "web" => "Medline"
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                          "pii" => "S0735109712026897"
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                          "issn" => "07351097"
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              "identificador" => "bib0160"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Asthma outcomes&#58; health care utilization and costs"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L&#46;J&#46; Akinbami"
                            1 => "S&#46;D&#46; Sullivan"
                            2 => "J&#46;D&#46; Campbell"
                            3 => "R&#46;W&#46; Grundmeier"
                            4 => "T&#46;V&#46; Hartert"
                            5 => "T&#46;A&#46; Lee"
                          ]
                        ]
                      ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.jaci.2011.12.984"
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                        "tituloSerie" => "J Allergy Clin Immunol"
                        "fecha" => "2012"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22386509"
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                      "titulo" => "World-wide variation in prevalence of symptoms of asthma&#44; allergic rhinoconjunctivitis and atopic eczema"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "The International Study of Asthma and Allergies in Childhood &#40;ISAAC&#41; Steering Committee"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "1998"
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        "texto" => "<p id="par0125" class="elsevierStylePara elsevierViewall">We thank the nurses of the Allergy Department of the Clinical University Hospital in Zaragoza &#40;Carmen Abad&#237;a&#44; Bertha Ariza&#44; Ascensi&#243;n Bretos&#44; Virginia Roche&#44; Javier Salda&#241;a and Lourdes Sobrino&#41; and the rest of the medical staff &#40;Mar Garc&#233;s&#44; Mar&#237;a Asunci&#243;n Dom&#237;nguez&#44; Mar&#237;a Dolores Y&#233;cora and Estibalitz Goienetxe&#41;&#46;</p> <p id="par0130" class="elsevierStylePara elsevierViewall">The Aragonese Foundation for Research Development in Allergology &#40;FADIA&#41; provided funding for this research&#46;</p>"
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ISSN: 03010546
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