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Sec. Pediatric Pulmonology
Volume 5 - 2017 | https://doi.org/10.3389/fped.2017.00082
Subcutaneous and Sublingual Immunotherapy in Allergic Asthma in Children
- 1Child Health Department, University of Ioannina School of Medicine, Ioannina, Greece
- 2Allergy Unit of the 3rd Pediatric Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- 3General Hospital of Ilias, Amaliada Hospital Unit, Amaliada, Greece
- 4Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
- 5Allergy Department, University Hospitals South Manchester NHS Trust, Manchester, UK
This review presents up-to-date understanding of immunotherapy in the treatment of children with allergic asthma. The principal types of allergen immunotherapy (AIT) are subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT). Both of them are indicated for patients with allergic rhinitis and/or asthma, who have evidence of clinically relevant allergen-specific IgE, and significant symptoms despite reasonable avoidance measures and/or maximal medical therapy. Studies have shown a significant decrease in asthma symptom scores and in the use of rescue medication, and a preventive effect on asthma onset. Although the safety profile of SLIT appears to be better than SCIT, the results of some studies and meta-analyses suggest that the efficacy of SCIT is better and that SCIT has an earlier onset than SLIT in children with allergic asthma. Severe, not controlled asthma, and medical error were the most frequent causes of SCIT-induced adverse events.
Asthma is one of the most common chronic inflammatory disorders in children, and airway remodeling can cause it to persist into adulthood. It affects up to 300 million people worldwide, and it is believed that an additional 100 million people will be suffering with asthma by 2025 (1). It has been shown that there are numerous asthma phenotypes from infancy to adulthood. Although asthma is not exclusively associated with allergy/atopy, about 75% of all children with asthma are atopic (1).
It is known that asthma pharmacotherapy can effectively control symptoms and the ongoing inflammatory process. However, it can not affect the underlying immune response; when medication is discontinued, symptoms may recur. This is where allergen immunotherapy (AIT) comes into play, as the only management that can interfere with the underlying immune pathophysiology. AIT is recommended for patients with moderate to severe allergic rhinitis with/without mild to moderate asthma due to inhalant allergens (2, 3). AIT is the only therapeutic method that may alter the natural course of allergy affecting both the development of new sensitizations and the clinical disease development (including deterioration of symptoms and progression of rhinitis to asthma) (4). The predominant mechanism is dependent on the type of allergen-specific TH cells (5). The efficacy of both subcutaneous subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) has been shown by systematic reviews and meta-analyses for both perennial and seasonal allergic respiratory disease (4, 6). However, the clinical evaluation of AIT must take into account the high heterogeneity among studies. Nevertheless, the Global Initiative for Asthma Report has been updated in 2017 and stated that potential benefits of AIT, compared to pharmacological and avoidance options, must be weighed against the risk of adverse effects, and the inconvenience and cost of the prolonged course of therapy (7).
The objective of the current review is to summarize the evidence for the efficacy, safety, potential barriers to, and facilitators of the use of AIT in pediatric asthma.
Subcutaneous immunotherapy is the term used to describe a process of repeated doses of a specific relevant allergen, for the treatment of IgE-mediated allergic disease (8). The conventional schedule for SCIT that employs unmodified allergen extracts consists of a weekly dose buildup by subcutaneous injections, followed by maintenance doses at 4 or 8 week intervals. Fewer buildup doses are possible with the use of modified allergenic extracts (such as allergoids), and/or adjuvants (9).
Sublingual immunotherapy is an alternative approach of allergen immunotherapy, whereby allergens are administered orally and—more specifically—by the sublingual route. In SLIT the allergen is given as either a dissolvable tablet or an aqueous/liquid extract (10), and the time interval between each maintenance dose varies from one product to another; generally, the once-a-day administration is preferred (11).
History of SCIT
In 1911, Dr. L. Noon and Dr. J Freeman published their findings on allergy desensitization through subcutaneous injections of pollen extract. By 1935, Cooke and colleagues identified a protective factor in serum, which was induced by AIT. This finding led to the concept of “blocking antibodies” (12). In 1953, Johnstone and Dutton randomized all children attending their clinic to receive either treatment (higher doses of SCIT) or placebo. The asthma symptoms of the treatment group resolved after 4 years (12).
After the second World War, aluminum hydroxide (Alum) was used as adjuvant in most allergen preparations. In the last decades, other modalities were tried, showing promising results (13). Other modifications also took place such as the use of inactivated allergoids in order to reduce their ability to bind to IgE, while retaining their ability to stimulate immune responses (12). In 1986, however, concerns were raised in the UK regarding the safety of desensitization, as several severe reactions had occurred in people with asthma. As a result, regulatory authorities prohibited SCIT in the UK outside of clinics that were familiar with its use and had appropriate resuscitation facilities. In the United States, serious adverse events (AEs) were reported in patients with relatively mild disease, and severe reactions kept being reported until the end of the century (14). These concerns about safety and a need to perhaps simplify administration led to various improvements, and also to the development of SLIT.
History of SLIT
Oral and sublingual route for the administration of allergen extracts was attempted in the 1900s, and the available vaccines were single allergen preparations (15); these efforts, however, failed to establish this method at the time. In the 1980s, several landmark studies kept demonstrating the safety and effectiveness of SLIT. Since 1986 there has been a revival of interest in SLIT.
Currently, there is no difference between the allergens used for SLIT and SCIT, although there are differences in the product quality requirements for each method (e.g., natural allergen extracts versus recombinant allergens) (16, 17).
Sublingual immunotherapy is now being used routinely in some parts of Europe (especially Italy and France) and is gradually spreading to Northern Europe and the United States. The introduction of SLIT could widen the scope of AIT and allow an increased number of patients to receive therapy (12).
Mechanisms of Immunotherapy to Aeroallergens
With AIT, allergen extracts are presented to the immune system either subcutaneously (SCIT) or sublingually (SLIT). As the patient is already sensitized to the allergens in question, they react with a localized immune response. The allergens arrive in local lymph nodes either unbound via free diffusion or are taken up by dendritic or B cells (18). Breg cells, which also play a key role in the induction of immune tolerance to allergens, can suppress allergen-mediated inflammation through secretion of IL-10 and TGF-β. Thereby, effector T-cell responses are suppressed, and Treg cells are induced (19). Likewise, Breg cells might promote allergen tolerance through preferential production of IgG4 antibodies on differentiation to plasma cells. Further, B-cells produce IgG4 antibodies, which bind to the allergens without initiating a reaction, thus acting as “blocking antibodies” (20). In a recent study, the authors showed that Bregs were less prevalent in lungs of mice after allergen exposure confirming that the development of asthma alters the homeostasis of IL-10+ regulatory B cells, emphasize the importance of B cells in asthma, not only as IgE producers but also as suppressive cells able to constrain the pathological process (21). Additionally, Tregs cells suppress allergic responses directly and indirectly. They migrate from the site of their development in the lymph nodes back to the area of inflammation and release IL-10 and TGF-β, thereby reducing local inflammation (22). IL-10 can decrease B cell antigen-specific IgE production and increase IgG4 levels; reduce proinflammatory cytokine release from mast cells, eosinophils, and T cells; and elicit tolerance of T cells. As a consequence, responses to allergens are reduced after induction of regulatory T cells (23). The data also support the concept of a later allergen-specific immune deviation from a TH2 to a TH1 cytokine profile (24). Furthermore, Tregs suppress effector Th1/Th2/Th17 cells, allergen-specific IgE, mast cells/basophils/eosinophils; inhibit migration of effector T cells to tissues; and facilitate release of IgG4 (25).
A schematic representation of the mechanisms involved in AIT is shown in Figure 1.
Figure 1. A schematic representation of the mechanisms involved in AIT [modified from Akdis and Akdis (22)]. Allergen IT results in both a shift in allergen-specific T-cells from Th2 to Th0/Th1, and in generation of IL-10- and TGF-β-producing T regulatory (Treg) cells. Treg cells affect B cells directly or indirectly by facilitating IgG4 and IgA release and hindering IgE development; also, they impede Th2 cell homing to tissues; they suppress mast cells, basophils, and eosinophils via direct and indirect mechanisms; and they inhibit epithelial cell activation. In addition, Breg cells also suppress effector T cells and contribute to IgG4 synthesis.
Selection of patients for immunotherapy requires identification of the underlying antigenic trigger by combination of clinical history taking, and skin prick tests and/or blood tests for allergen-specific IgE (26). The current ARIA guidelines (27) give both SCIT and SLIT a conditional recommendation in allergic asthma, due to moderate/low quality of evidence. The majority of the guidelines agree that appropriate candidates for AIT are mainly children with allergic asthma that is difficult to control with conventional treatments. Asthma, nevertheless, must be well controlled by standard pharmacological treatment at the time the injection is administered, due to safety concerns (28). It is of particular interest in patients, who are sensitized to several pollens, to prescribe AIT only for major allergens (29), with the aim to increase the effectiveness of AIT and to better select patients who need a treatment. Hence, the use of molecular diagnosis techniques [component-resolved diagnostics (CRD)] (30) may allow physicians to better identify whether children with allergic respiratory symptoms are sensitized to major allergens or to cross-reactive molecules (31). In this context, an observational multicenter survey carried out by the Italian Pediatric Allergy Network suggest that a higher cutoff point of SPT-induced wheal reactions (e.g., 5 mm) should be used to take decisions when a confirmatory CRD assay cannot be implemented (32). In the UK, AIT is rarely used for asthma, partly because of the risk of adverse reaction with SCIT in uncontrolled asthma, and partly because of the lack of evidence for its cost-effectiveness versus the currently available routine treatments (33). Several factors may influence the decision for immunotherapy either way, such as poor adherence, clinically irrelevant allergens, poly-sensitizations, unavoidable adverse reactions of routine medication, etc. (34). Furthermore, the prescription of AIT depends also on the severity of the allergic asthma and duration of symptoms. Key parameters to evaluate the severity are the need of additional specialist visits; the response to pharmacotherapy and the recurrence of symptoms impairing school or sport activities or altering sleep quality (35). The decision between SCIT or SLIT hinges on several factors, including product availability, cost, patients ability to consistently attend the clinic, patient’s characteristics, physician’s/patient’s preference, etc. (4). Also, SLIT could be tried if SCIT causes systemic reactions (34). Indications for SCIT and SLIT are summarized in Table 1.
Table 1. Indications and contraindications for subcutaneous immunotherapy and sublingual immunotherapy (SLIT) in asthmatic children.
The contraindications for SCIT or SLIT are either absolute contraindications (serious immunologic disease, major cardiovascular disease, cancer, chronic infections, lack of compliance, severe psychological disorders, etc.), or relative contraindications (pregnancy) (36). Severe asthma or uncontrolled asthma (regardless of its severity) is major risk factor for serious or even fatal adverse reactions and, therefore, represent important contraindications for SLIT/SCIT (37, 38). Interestingly, well-controlled asthma, regardless of its severity, was thought to not be a contraindication for AIT in a recent EAACI position paper (36). However, the strength of this recommendation was variable (36), and more evidence should become available before AIT can be safely considered for patients with severe asthma, even if well controlled. Partially controlled asthma is a relative contraindication for AIT in the same paper (36). Accordingly, German guidelines suggest that AIT may be performed in children with partially controlled asthma (39). Furthermore, well-controlled asthma, regardless of its severity, is not a contradiction for AIT (36). Any other condition that would reduce the patient’s ability to survive a potential systemic allergic reaction could also be a relative contraindication (28). SLIT should not be administered in case of acute inflammation, injury and surgical interventions in the oral cavity, or acute gastroenteritis (39). Some contradictions are listed in Table 1.
Duration of Treatment
It is generally accepted that 3–5 years are required to achieve a clinical benefit and to maintain it after treatment cessation, for either SCIT or SLIT (39). Two studies showed no differences in the efficacy between a 3 and a 5 years course of house dust mite (HDM) in asthmatic children, or in the persistence of clinical benefit after discontinuation (40, 41). In another AIT study in asthmatic children sensitized to HDM, improvement has been shown from the first year of treatment (42, 43). The duration of the treatment may be prolonged (5 years or more), depending on the clinical response of subjects. Many patients experience a prolonged remission of symptoms after discontinuation of AIT (44, 45) whereas others may have a relapse of clinical manifestations. Currently, there are no specific laboratory tests or biomarker that can distinguish patients who will relapse from those who would have a prolonged clinical remission after discontinuing AIT (45). In keeping with that evidence, 3 years of SLIT in HDM sensitized children with asthma had a medication-sparing effect (46). The data are unclear, however, regarding the extend of the medication-sparing effect of AIT, with one study reporting no change in the asthma medication score after 1 year of treatment (43), whereas a pronounced effect was shown in a different work (42). Early treatment termination is a major problem (47) as only 35.4% of children were found to have completed at least 3 years of treatment (48). If AIT has been administrated for a number of years, current evidence suggests that it could induce long-term benefits, after its cessation (40, 46, 49). In any case, the duration of AIT should be individualized on the basis of the patient’s clinical response, disease severity, AEs, and patient preference (28).
Position papers and practice parameters recommend well-standardized protocols for SCIT in asthma. Pajno et al. showed that during the first year of SLIT for children with rhinitis/asthma because of grass pollen, the continuous regimen performed better than the pre/co-seasonal; however, no significant difference was shown in the subsequent 2 years (50). Currently, there is no clear evidence of superiority for the pre/co-seasonal for pollen allergens (11). Nevertheless, due to improved adherence and better cost-effectiveness, pre/co-seasonal regimens are often preferred (38).
AIT is generally effective in asthmatic children who do not fully respond to asthma medication and environmental control. Nevertheless, it should be kept in mind that maintenance of asthma control via pharmacotherapy is vital both before and during AIT (51, 52). Several studies evaluating the efficacy of SCIT (53, 54) and SLIT (7, 55) have demonstrated effectiveness in controlling asthma symptom and reducing the medication use. A recent systematic review also concluded that SCIT and SLIT appear to be efficacious for the treatment of rhinitis and asthma in children (56).
Efficacy of SCIT
There is consensus that SCIT for asthma induced by the most common aeroallergens (grass, mite, and cat dander) is generally efficacious (57). The efficacy of SCIT for the treatment of asthma, including a steroid—sparing effect, was evaluated in a meta-analysis including 101 studies (3,792 patients) carried out both in adults and in children (53). In particular, 42 studies of AIT involved patients with mite allergy, 27 pollen allergy (mostly grasses), 10 animal dander allergy, 2 Cladosporium allergy, 2 latex allergy, and 6 patients with multiple aeroallergens allergy. A significant reduction of symptoms was found in patients treated with mite and pollen AIT, while no significant improvement was recorded for animal dander or allergenic mixtures. Despite the heterogeneity of the included studies, the overall reduction of symptoms (for all allergens), the medication scores, and the bronchial hyperreactivity were significantly reduced, too. Saporta et al. evaluated 99 children and adults in regards to symptom score before and after either SCIT or SLIT. Coughing seemed to respond better to SCIT (P = 0.037), and wheezing to SLIT (P = 0.024), though both symptoms significantly improved regardless of regimen. For the remaining symptoms, there was no significant difference between SCIT and SLIT (58).
Efficacy of SLIT
The evidence for clinical efficacy of SLIT is not abundant, but good efficacy is generally reported for HDM, and grass pollen allergens. A recent review found a relative efficacy of SLIT (symptoms and/or medication score) in adults and children from 20 to 40% (7). With respect to appropriate doses, the 300 IR (index of reactivity) dose of SLIT is thought to offer optimal efficacy and tolerability for HDM-induced asthma (59). A meta-analysis that included 9 studies on 441 asthmatic children found a significant decrease in symptom and medication scores with SLIT, in comparison to placebo (60). In another meta-analysis that evaluated 9 studies in 452 HDM-allergic children aged 3–18 years with asthma treated with SLIT, marked improvement in asthma symptoms and medication scores, and a steroid-sparing effect was seen (61). Overall, the reviews of the literature on pediatric populations consistently support the efficacy and safety of SLIT compared to placebo.
In order to reduce the risk of adverse effects, AIT starts with very low doses that increase within the first few weeks to months of treatment (buildup/up-dosing phase), and until a maintenance dose is reached (28, 62). This does not, however, eliminate the risk of reactions, which is directly dependent on several factors such as allergen extract, injection schedule, dose, and patient factors (63). Such reactions could be local (in the immediate vicinity of the administration site) and systemic (SR), which can be further characterized as fatal, anaphylaxis, and systemic reactions not otherwise classified (wheezing and urticarial etch) (53). In most cases, symptoms can be managed if they are treated early.
The incidence of systemic reactions for AIT varies between 0.06 and 1.01% in those receiving SC dosing (64). In a recent prospective European survey, 762 children and 801 adolescents with AR (93.7%), AR and asthma (56.1%), and asthma alone (5.2%) had been included; they were sensitized to pollens (45%), mites (36.8%), dander (10.2%), or they were polysensitized (62.5%). A total of 29 reactions had been recorded, 23 by SCIT, and 6 by SLIT. The only three cases of anaphylaxis were related to SCIT, and they had a delayed onset (>2 h after administration) (65). Current recommendations suggest that children undergoing SCIT are observed for at least 30 min after injection (3, 66).
Typically, asthma is considered to be a risk factor for SRs, especially when it is uncontrolled (36). Other risk factors include polysensitization, grass pollen sensitization and—regarding SCIT—the use of natural extracts versus allergoids (65). All allergen preparations, such as standardized extracts (67), allergoids (68), or recombinant allergens (69), can cause side effects. Hence, research is being conducted to produce extracts using modified proteins or peptides that may increase safety and efficacy (33).
Sublingual immunotherapy appears to be quite safe for pediatric patients. In an observational study of 193 children receiving SLIT, who had a history of allergic rhinitis with or without asthma, there were nearly 500 mild/local adverse reactions but only 1 SR (severe asthma attack) (70). The main local AEs are oral/throat itching and mouth/tongue edema. In children, gastrointestinal complains have been mostly described during SLIT with HDM (7). Local symptoms can be, however, severe enough to warrant discontinuation of treatment. A grading system has been suggested with grade 1 corresponding to mild symptoms, grade 2 to moderate symptoms that require systemic treatment, and grade 3 to severe symptoms that could prompt termination of the SLIT regimen (7). The incidence of SRs with SLIT does not appear to be dose dependent, unlike SCIT where SRs are associated with higher allergen dose (71). A recent review summarized over 80 randomized double-blind placebo-controlled trials, and several reviews of both adult and children populations and concluded that, in most studies, the overall occurrence of systemic side effects is similar between placebo and active groups (7). To date, only few cases of anaphylaxis have been reported with SLIT (38), and some of these are probably due to overdose (72).
Preventive Effect of AIT
Allergen-specific immunotherapy (AIT) is the only treatment capable of disease modification, as demonstrated by prevention of new sensitizations and inhibition of disease progression, especially in children monosensitized to HDM (73, 74). Due to its disease-modifying effects, AIT may be the closest that we currently have to a cure for allergic asthma (4). In the “Preventive allergy treatment (PAT) study,” SCIT with birch and/or grass pollen reduced the risk of asthma development in children with allergic rhinoconjunctivitis (75). This effect was detectable 7 years following discontinuation of SCIT (76).
Sublingual immunotherapy was also shown to have a preventive effect in a study in which 113 children, aged 5–14 years with seasonal rhinitis due to grass pollen, were randomly allocated to pharmacotherapy plus SLIT, or pharmacotherapy only. After 3 years, only 8 of 45 SLIT patients had developed asthma as opposed to 18 of 44 controls (confidence interval: 1.5–10) (77). In another trial, 216 children aged 5–17 who had rhinitis with/without intermittent asthma received conventional medication plus SLIT, or medication only. After 3 years of observation, the prevalence of persistent asthma was 1.5 and 30% for SLIT and the control group, respectively (78). In a further study, the same authors prospectively evaluated the long-term effect of SLIT in 59 patients, compared with 12 control subjects. The total duration of the follow-up was 15 years. All the control subjects developed positive tests to allergens previously negative, while this occurred in less than a quarter of the patients receiving SLIT (44). Zolkipli et al. could recently demonstrate a significant reduction in sensitization to new allergens in children prophylactically treated with SLIT. This was a prospective, randomized DBPC, proof-of-concept study involving 111 infants <1 year of age at high risk of atopy (positive atopic family history) with no sensitization to common allergens at randomization. After a year of treatment with a high-dose HDM SLIT, there was a 50% reduction in sensitization to any allergen in the active group (79).
Allergen immunotherapy for inhalant allergens is usually not considered for infants and toddlers. Although both SCIT and SLIT have been employed in children under 5 years and they appear to be effective (80), the evidence for the use of immunotherapy in this group is limited (81). For practical reasons, immunotherapy is not generally offered to patients below the age of 5, while for older ages there is no upper limit (82). In any case, each patient should be evaluated individually by considering the benefits and risks (83). SLIT drops are generally preferred for younger children over SCIT (48).
According to the review by Calderon et al., 50–80% of patients with allergies are polysensitized. This impedes appropriate selection of patients for immunotherapy (37) and renders the clinical history vital in the identification of the clinically relevant allergen(s) (84). The use of in vitro component-based IgE diagnostics can increase the likelihood of AIT being successful, by facilitating correct identification of the culprit allergen (39). Multiallergen immunotherapy is currently supported by little evidence, both regarding its efficacy and successful induction of immunological tolerance (37). Also, there are conflicting results for the efficacy of allergen mixes (85). Thus, large clinical trials are needed before SCIT and/or SLIT can be routinely carried out with an allergen mixture or concomitant use of several allergens in polysensitized patients.
Omalizumab and AIT
Omalizumab pretreatment has been shown to improve the safety and tolerability of cluster and rush immunotherapy schedules (86, 87). Additionally, omalizumab in combination with immunotherapy is more effective that AIT alone in managing symptoms (87). Treatment of >6 months with omalizumab was clinically effective in patients with severe uncontrolled asthma who could not tolerate immunotherapy (63, 88). This effect of omalizumab allowed the initiation of AIT in children with severe asthma. However, studies investigating AIT with omalizumab pretreatment and/or AIT-omalizumab combinations are lacking in children with severe asthma; further research is needed to evaluate the risk/benefit ratio of such regimens (63).
SCIT vs SLIT
There is conflicting evidence regarding which method is more effective. Chelladurai et al. showed little difference in treatment effectiveness when comparing SCIT with SLIT (89). From four dust mite studies, two studies favored SCIT in reducing medication use and two favored SLIT, while a birch study found SLIT to be more effective (89). A meta-analysis by Nelson found that SCIT was superior to SLIT (90). In general, although both SCIT and SLIT appear to be effective in allergic asthma, literature is more supportive of an SCIT predominance in clinical efficacy (91).
In regards to safety, SLIT appears to be better tolerated than SCIT. The majority of SLIT AEs are local reactions (e.g., oromucosal pruritus) that appear at the start of treatment and resolve within a few days or weeks, without any medical intervention. Only, a few cases of SLIT-related anaphylaxis have been reported (92). A novel approach for AIT in which SCIT is administered in the buildup phase and SLIT in the maintenance phase in a randomized, controlled, prospective manner in HDM–sensitive asthmatic children was conducted. The novel regimen proposed seems to successfully combine the advantages of both routes without loss of clinical benefit and might be a promising alternative in children undergoing AIT (93).
It is important that AIT is carried out in accordance with prescriber’s recommendations (2, 94). Adherence to therapy and the likelihood of treatment success are improved by thoroughly informing the patient about the way AIT works. Studies conducted on SCIT showed that the major cause of non-compliance was the inconvenience related to injections, and the cost of treatment (90). SLIT, on the other hand, had different compliance issues as it is administered at home by patients themselves. Although it was initially thought that SLIT would have a much better compliance than SCIT due to omitting the requirement to regularly attend clinics, it was soon shown that adherence to SLIT was not significantly better; this is probably because SLIT faces similar adherence problems with other conventional pharmacotherapy regimens (95).
Studies comparing cost-effectiveness between patients treated for 3 years with AIT versus those treated with pharmacotherapy alone have found that AIT might be associated with cost savings as high as 80% 3 years after completion of treatment (4). Nevertheless cost-effectiveness is difficult to review due to different national health systems, variable epidemiologic data, and different prescription habits and outcome measures used in studies (96). However, in general, AIT’s cost-effectiveness appears to be good, as demonstrated by several pharmacoeconomics studies conducted within 6 years of treatment initiation (9).
AIT appears to be effective in children with IgE-mediated asthma who do not fully respond to the conventional anti-asthmatic medications and environmental control and currently represents the only therapeutic approach capable to modify the natural evolution of a respiratory allergy. Its steroid-sparing effect is an important benefit for patients who have to use these drugs in high doses and in long-term regimens. Both SCIT and SLIT appear to be effective in allergic asthma, although some reports suggest that the efficacy of SCIT may be better. Uncontrolled asthma remains a significant risk factor for side effects, and AIT should not be considered on safety grounds for patients who cannot get their symptoms reasonably under control with pharmacotherapy alone. As we are entering the era of personalized medicine, further research should be conducted with a view to individualize AIT using recombinant antigen technology: this way we could perhaps create allergen extracts against specific proteins to which the patient is allergic, or extracts with modified proteins or peptides that could increase safety/efficacy. Adjuvants that can stimulate the immune system are currently being developed. These approaches have the potential to transform AIT to a mainstream, first line therapy in the foreseeable future.
ST had the conception and designed the work. ST, AM, and GF collected the data. All the authors contributed to the data analysis and its interpretation. ST and GG made the critical revision of the article, and GG gave his final approval of the version to be published.
Conflict of Interest Statement
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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35. Pajno GB, Bernardini R, Peroni D, Arasi S, Martelli A, Landi M, et al. Clinical practice recommendations for allergen-specific immunotherapy in children: the Italian consensus report. Ital J Pediatr (2017) 43(1):13. doi:10.1186/s13052-016-0315-y
36. Pitsios C, Demoly P, Bilo MB, Gerth van Wijk R, Pfaar O, Sturm GJ, et al. Clinical contraindications to allergen immunotherapy: an EAACI position paper. Allergy (2015) 70(8):897–909. doi:10.1111/all.12638
37. Scadding GW, Calderon MA, Bellido V, Koed GK, Nielsen NC, Lund K, et al. Optimisation of grass pollen nasal allergen challenge for assessment of clinical and immunological outcomes. J Immunol Methods (2012) 384(1–2):25–32. doi:10.1016/j.jim.2012.06.013
38. Calderon MA, Simons FER, Malling HJ, Lockey RF, Moingeon P, Demoly P. Sublingual allergen immunotherapy: mode of action and its relationship with the safety profile. Allergy (2012) 67:302–11. doi:10.1111/j.1398-9995.2011.02761.x
39. Pfaar O, Bachert C, Bufe A, Buhl R, Ebner C, Eng P, et al. Guideline on allergen-specific immunotherapy in IgE-mediated allergic diseases: S2k Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Society for Pediatric Allergy and Environmental Medicine (GPA), the Medical Association of German Allergologists (AeDA), the Austrian Society for Allergy and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Dermatology (DDG), the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), the German Society of Pediatrics and Adolescent Medicine (DGKJ), the Society for Pediatric Pneumology (GPP), the German Respiratory Society (DGP), the German Association of ENT Surgeons (BV-HNO), the Professional Federation of Paediatricians and Youth Doctors (BVKJ), the Federal Association of Pulmonologists (BDP) and the German Dermatologists Association (BVDD). Allergo J Int (2014) 23(8):282–319. doi:10.1007/s40629-014-0032-2
40. Stelmach I, Sobocińska A, Majak P, Smejda K, Jerzyńska J, Stelmach W. Comparison of the long-term efficacy of 3- and 5-year house dust mite allergen immunotherapy. Ann Allergy Asthma Immunol (2012) 109(4):274–8. doi:10.1016/j.anai.2012.07.015
42. Eifan AO, Akkoc T, Yildiz A, Keles S, Ozdemir C, Bahceciler NN, et al. Clinical efficacy and immunological mechanisms of sublingual and subcutaneous immunotherapy in asthmatic/rhinitis children sensitized to house dust mite: an open randomized controlled trial. Clin Exp Allergy (2010) 40(6):922–32. doi:10.1111/j.1365-2222.2009.03448.x
43. Yukselen A, Kendirli SG, Yilmaz M, Altintas DU, Karakoc GB. Effect of one-year subcutaneous and sublingual immunotherapy on clinical and laboratory parameters in children with rhinitis and asthma: a randomized, placebo-controlled, double-blind, double-dummy study. Int Arch Allergy Immunol (2012) 157(3):288–98. doi:10.1159/000327566
44. Marogna M, Spadolini I, Massolo A, Canonica GW, Passalacqua G. Long-lasting effects of sublingual immunotherapy according to its duration: a 15-year prospective study. J Allergy Clin Immunol (2010) 126(5):969–75. doi:10.1016/j.jaci.2010.08.030
45. Karakoc-Aydiner E, Eifan AO, Baris S, Gunay E, Akturk E, Akkoc T, et al. Long-term effect of sublingual and subcutaneous immunotherapy in dust mite-allergic children with asthma/rhinitis: a 3-year prospective randomized controlled trial. J Investig Allergol Clin Immunol (2015) 25(5):334–42. Erratum in: J Investig Allergol Clin Immunol (2016) 26(2):144.
46. Ozdemir C, Yazi D, Gocmen I, Yesil O, Aydogan M, Semic-Jusufagic A, et al. Efficacy of long-term sublingual immunotherapy as an adjunct to pharmacotherapy in house dust mite-allergic children with asthma. Pediatr Allergy Immunol (2007) 18(6):508–15. doi:10.1111/j.1399-3038.2007.00549.x
49. Arroabarren E, Tabar AI, Echechipía S, Cambra K, García BE, Alvarez-Puebla MJ. Optimal duration of allergen immunotherapy in children with dust mite respiratory allergy. Pediatr Allergy Immunol (2015) 26(1):34–41. doi:10.1111/pai.12296
50. Pajno GB, Caminiti L, Crisafulli G, Vita D, Valenzise M, De Luca R, et al. Direct comparison between continuous and coseasonal regimen for sublingual immunotherapy in children with grass allergy: a randomized controlled study. Pediatr Allergy Immunol (2011) 22(8):803–7. doi:10.1111/j.1399-3038.2011.01196.x
51. Blumberga G, Groes L, Haugaard L, Dahl R. Steroid-sparing effect of subcutaneous SQ-standardised specific immunotherapy in moderate and severe house dust mite allergic asthmatics. Allergy (2006) 61(7):843–8. doi:10.1111/j.1398-9995.2006.01088.x
52. Maestrelli P, Zanolla L, Pozzan M, Fabbri LM. Regione Veneto Study Group on the “Effect of immunotherapy in allergic A. Effect of specific immunotherapy added to pharmacologic treatment and allergen avoidance in asthmatic patients allergic to house dust mite”. J Allergy Clin Immunol (2004) 113(4):643–9. doi:10.1016/j.jaci.2003.12.586
54. Ross RN, Nelson HS, Finegold I. Effectiveness of specific immunotherapy in the treatment of asthma: a meta-analysis of prospective, randomized, double-blind, placebo-controlled studies. Clin Ther (2000) 22(3):329–41. doi:10.1016/S0149-2918(00)80037-5
55. Olaguíbel JM, Álvarez Puebla MJ. Efficacy of sublingual allergen vaccination for respiratory allergy in children. Conclusions from one meta-analysis. J Invest Allergol Clin Immunol (2005) 15(1):9–16.
56. Kim JM, Lin SY, Suarez-Cuervo C, Chelladurai Y, Ramanathan M, Segal JB, et al. Allergen-specific immunotherapy for pediatric asthma and rhinoconjunctivitis: a systematic review. Pediatrics (2013) 131(6):1155–67. doi:10.1542/peds.2013-0343
59. Demoly P, Passalacqua G, Calderon MA, Yalaoui T. Choosing the optimal dose in sublingual immunotherapy: rationale for the 300 index of reactivity dose. Clin Transl Allergy (2015) 5:44. doi:10.1186/s13601-015-0088-1
60. Rodríguez-Pérez N, Ambriz-Moreno Mde J, Canonica GW, Penagos M. Frequency of acute systemic reactions in patients with allergic rhinitis and asthma treated with sublingual immunotherapy. Ann Allergy Asthma Immunol (2008) 101(3):304–10. doi:10.1016/s1081-1206(10)60496-6
61. Compalati E, Passalacqua G, Bonini M, Canonica GW. The efficacy of sublingual immunotherapy for house dust mites respiratory allergy: results of a GA2LEN meta-analysis. Allergy (2009) 64(11):1570–9. doi:10.1111/j.1398-9995.2009.02129.x
65. Rodríguez Del Río P, Vidal C, Just J, Tabar AI, Sanchez-Machin I, Eberle P, et al. The European survey on adverse systemic reactions in allergen immunotherapy (EASSI): a paediatric assessment. Pediatr Allergy Immunol (2017) 28(1):60–70. doi:10.1111/pai.12660
67. Passalacqua G, Durham RS; Global Allergy and Asthma European Network. Allergic rhinitis and its impact on asthma update: allergen immunotherapy. J Allergy Clin Immmunol (2007) 119:881–91. doi:10.1016/j.jaci.2007.01.045
68. Corrigan CJ, Kettner J, Doemer C, Cromwell O, Narku A. Efficacy and safety of preseasonal-specific immunotherapy with an aluminium absorbed six-grass allergoid. Allergy (2005) 60:801–7. doi:10.1111/j.1398-9995.2005.00790.x
69. Jutel M, Jaeger L, Suck R, Meyer H, Math D, Fiebig H, et al. Allergen-specific immunotherapy with recombinant grass pollen allergens. J Allergy Clin Immmunol (2005) 116:608–13. doi:10.1016/j.jaci.2005.06.004
70. Seidenberg J, Pajno GB, Bauer CP, La Grutta S, Sieber J. Safety and tolerability of seasonal ultra-rush, high-dose sublingual-swallow immunotherapy in allergic rhinitis to grass and tree pollens: an observational study in 193 children and adolescents. J Investig Allergol Clin Immunol (2009) 19(2):125–31.
71. Calderon MA, Larenas D, Kleine-Tebbe J, Jacobsen L, Passalacqua G, Eng PA, et al. European Academy of Allergy and Clinical Immunology task force report on ‘dose-response relationship in allergen-specific immunotherapy’. Allergy (2011) 66(10):1345–59. doi:10.1111/j.1398-9995.2011.02669.x
72. Duric-Filipovic I, Caminati M, Kostic G, Filipovic D, Zivkovic Z. Allergen specific sublingual immunotherapy in children with asthma and allergic rhinitis. World J Pediatr (2016) 12(3):283–90. doi:10.1007/s12519-016-0022-1
73. Harmanci K, Razi CH, Toyran M, Kanmaz G, Cengizlier MR. Evaluation of new sensitizations in asthmatic children monosensitized to house dust mite by specific immunotherapy. Asian Pac J Allergy Immunol (2010) 28(1):7–13.
74. Inal A, Altintas DU, Yilmaz M, Karakoc GB, Kendirli SG, Sertdemir Y. Prevention of new sensitizations by specific immunotherapy in children with rhinitis and/or asthma monosensitized to house dust mite. J Investig Allergol Clin Immunol (2007) 17(2):85–91.
75. Niggemann B, Jacobsen L, Dreborg S, Ferdousi HA, Halken S, Host A, et al. Five-year follow-up on the PAT study: specific immunotherapy and long-term prevention of asthma in children. Allergy (2006) 61(7):855–9. doi:10.1111/j.1398-9995.2006.01068.x
76. Jacobsen L, Niggemann B, Dreborg S, Ferdousi HA, Halken S, Host A, et al. Specific immunotherapy has long-term preventive effect of seasonal and perennial asthma: 10-year follow-up on the PAT study. Allergy (2007) 62(8):943–8. doi:10.1111/j.1398-9995.2007.01451.x
77. Novembre E, Galli E, Landi F, Caffarelli C, Pifferi M, De Marco E, et al. Coseasonal sublingual immunotherapy reduces the development of asthma in children with allergic rhinoconjunctivitis. J Allergy Clin Immunol (2004) 114(4):851–7. doi:10.1016/j.jaci.2004.07.012
78. Marogna M, Tomassetti D, Bernasconi A, Colombo F, Massolo A, Di Rienzo Businco A, et al. Preventive effects of sublingual immunotherapy in childhood: an open randomized controlled study. Ann Allergy Asthma Immunol (2008) 101:206–11. doi:10.1016/S1081-1206(10)60211-6
79. Zolkipli Z, Roberts G, Cornelius V, Clayton B, Pearson S, Michaelis L, et al. Randomized controlled trial of primary prevention of atopy using house dust mite allergen oral immunotherapy in early childhood. J Allergy Clin Immunol (2015) 136(6):1541–7.e1–11. doi:10.1016/j.jaci.2015.04.045
80. Eng PA, Borer-Reinhold M, Heijnen IA, Gnehm HP. Twelve-year follow-up after discontinuation of preseasonal grass pollen immunotherapy in childhood. Allergy (2006) 61(2):198–201. doi:10.1111/j.1398-9995.2006.01011.x
82. Zuberbier T, Bachert C, Bousquet PJ, Passalacqua G, Walter Canonica G, Merk H, et al. GA(2) LEN/EAACI pocket guide for allergen-specific immunotherapy for allergic rhinitis and asthma. Allergy (2010) 65(12):1525–30. doi:10.1111/j.1398-9995.2010.02474.x
83. Bernstein DI, Wanner M, Borish L, Liss GM; Immunotherapy Committee, American Academy of Allergy, Asthma and Immunology. Twelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001. J Allergy Clin Immunol (2004) 113(6):1129–36. doi:10.1016/j.jaci.2004.02.006
86. Kopp MV, Hamelmann E, Bendiks M, Zielen S, Kamin W, Bergmann KC, et al. Transient impact of omalizumab in pollen allergic patients undergoing specific immunotherapy. Pediatr Allergy Immunol (2013) 24(5):427–33. doi:10.1111/pai.12098
87. Kuehr J, Brauburger J, Zielen S, Schauer U, Kamin W, Von Berg A, et al. Efficacy of combination treatment with anti-IgE plus specific immunotherapy in polysensitized children and adolescents with seasonal allergic rhinitis. J Allergy ClinImmunol (2002) 109(2):274–80. doi:10.1067/mai.2002.121949
88. Braido F, Corsico A, Rogkakou A, Ronzoni V, Baiardini I, Canonica GW. The relationship between allergen immunotherapy and omalizumab for treating asthma. Expert Rev Respir Med (2015) 9(2):129–34. doi:10.1586/17476348.2015.1000866
89. Chelladurai Y, Suarez-Cuervo C, Erekosima N, Kim JM, Ramanathan M, Segal JB, et al. Effectiveness of subcutaneous versus sublingual immunotherapy for the treatment of allergic rhinoconjunctivitis and asthma: a systematic review. J Allergy Clin Immunol Pract (2013) 1(4):361–9. doi:10.1016/j.jaip.2013.04.005
90. Nelson HS, Makatsori M, Calderon MA. Subcutaneous immunotherapy and sublingual immunotherapy: comparative efficacy, current and potential indications, and warnings – United States versus Europe. Immunol Allergy Clin North Am (2016) 36(1):13–24. doi:10.1016/j.iac.2015.08.005
92. Canonica GW, Cox L, Pawankar R, Baena-Cagnani CE, Blaiss M, Bonini S, et al. Sublingual immunotherapy: world allergy organization position paper 2013 update. World Allergy Organ J (2014) 7(1):6. doi:10.1186/1939-4551-7-6
93. Keles S, Karakoc-Aydiner E, Ozen A, Izgi AG, Tevetoglu A, Akkoc T, et al. A novel approach in allergen-specific immunotherapy: combination of sublingual and subcutaneous routes. J Allergy Clin Immunol (2011) 128(4):808–15.e7. doi:10.1016/j.jaci.2011.04.033
94. Alvarez-Cuesta E, Bousquet J, Canonica GW, Durham SR, Malling HJ, Valovirta E. Standards for practical allergen-specific immunotherapy. Allergy (2006) 61(Suppl 82):1–20. doi:10.1111/j.1398-9995.2006.01219_1.x
95. Jutel M, Bartkowiak-Emeryk M, Bręborowicz A, Cichocka-Jarosz E, Emeryk A, Gawlik R, et al. Sublingual immunotherapy (SLIT) – indications, mechanism, and efficacy. Ann Agric Environ Med (2016) 23:44–53. doi:10.5604/12321966.1196851
Keywords: subcutaneous immunotherapy, sublingual immunotherapy, children, allergy, asthma
Citation: Tsabouri S, Mavroudi A, Feketea G and Guibas GV (2017) Subcutaneous and Sublingual Immunotherapy in Allergic Asthma in Children. Front. Pediatr. 5:82. doi: 10.3389/fped.2017.00082
Received: 31 January 2017; Accepted: 05 April 2017;
Published: 21 April 2017
Edited by:Carlo Caffarelli, University of Parma, Italy
Copyright: © 2017 Tsabouri, Mavroudi, Feketea and Guibas. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Sophia Tsabouri, firstname.lastname@example.org

domain: literature


text:
We found 2 providers named 'Steven Pouls' nationally.
Dr. Steven Pouls practices family medicine. Dr. Pouls attended medical school at UMDNJ-School of Osteopathic Medicine. His areas of expertise include diabetes, obesity, and hypertension (high blood pressure). The average patient rating for Dr. Pouls is 4.5 stars out of 5. Dr. Pouls accepts Humana HMO, Humana Bronze, Humana Catastrophic, and more. He is professionally affiliated with Adventist Health Partners (AHP), Adventist Midwest Health - Patient Centered Medical Home Initiative (PCMH), and Adventist Medical Center GlenOaks.
Clinical interests: Hypertension, Diabetes, Obesity

domain: medical


text:
Oct 11, 2015; Arlington, TX, USA; Dallas Cowboys cheerleader performs during a timeout from the game against the New England Patriots at AT&T Stadium. Mandatory Credit: Matthew Emmons-USA TODAY Sports
Dallas Cowboys: 12-2, 1st NFC East, winner Super Bowl XII
Star Wars Episode IV – A New Hope: May 1977, $775.4 million box office
In the summer of 1977, the United States and then the rest of the world were taken by storm by a new science-fiction film that not only re-defined the genre, but also the entire film and toy industry. Complete with a cast of mostly unheard of talent, Star Wars (originally without ‘A New Hope’ in the title) took special effects to a completely new level.
This was not only a good time for Lucas, but also a great time to be a Cowboys fan.
Having already been to three Super Bowls previously, the ‘Doomsday Defense’ was still very much in force and would make itself a nation-wide household name following a disappointing end to the 1976 campaign when Dallas lost to the Los Angles Rams at Texas Stadium in the divisional round.
Whether “The Force’ was with head coach Tom Landry or not, the Cowboys would enjoy one of the finest seasons in franchise history following the release of the original Star Wars.
School children would wear Cowboys t-shirts while carrying Star Wars lunch pails to school all over the country.
The Cowboys began the season 8-0 before dropping back-to-back games against the St. Louis Cardinals and Pittsburgh Steelers, who were already winners of two Super Bowls during the decade. Those would be the only two defeats during the only 14-game schedule to follow the release of a Star Wars film in the same year.
The Cowboys complete shutdown of the Denver Broncos in Super Bowl XII at the Louisiana Superdome left no question that the Cowboys, along with Star Wars, would become a national interest for the long haul – this trend exists to this day.
While America’ favorite movie was doing what it did, the Dallas Cowboys were rapidly becoming America’s Team, an unofficial title that’s still confirmed each time this team plays anywhere outside of North Texas.

domain: news


text:
With only a few days left to get your personalised orders in for this Christmas we thought it was the perfect time to go over what a monogram is and why you should have your kit personalised...
Since When? Originating back in 350BC a monogram was a motif made by overlapping or combining two or more letters or other graphemes to form one symbol. Monograms are often made by combining the initials of an individual or a company, used as recognizable symbols or logos.
In todays day and age the monogram has been simplified and instead of overlapping and creating a graphic it is simply your initals with or without punctuation.
Why use it? A monogram is a classic and personal touch traditionally used on items of importance or significance. Just like a royal seal it denotes importance and implies sophistication, as having something personalised incurs extra expense and is always worth the wait.
When? If your giving a gift and you want to show that person just how important they are to you then this is that extra step. It could be for any occasion birthday, fathers day, mothers day, congratulations for retirement or landing the dream job. Monograms are on goods carried by important people, so if you want that special someone to feel they are at the top of your list then monogrammed goods are the way to do it.
Now more than ever it's easy to add a monogram to any Hammered Leatherworks goods. You simply select-->
Yes please and type the initials and WHIZ BANG POP a custom piece will be on its way to you.
Adam and Bec Fogarty
VISIT US AT

domain: design


text:
Objectives: To report the opinions of specialist orthodontists regarding the profile, characteristics and treatment of adults currently undergoing orthodontic treatment in the Republic of Ireland (ROI)
Design/setting: A national cross-sectional questionnaire study in the ROI.
Method: A pilot-tested questionnaire was distributed to 122 specialist orthodontists in the ROI. Questions addressed general and treatment information for current adult orthodontic patients. Those whose treatment involved orthognathic surgery were not excluded.
Results: A response of 83% was obtained. Ninety-five per cent of specialists reported treating adults, most of whom were self-referred and were typically professional, female and aged 25-35 years. The overall ratio quoted of professionals to non-professionals was almost 3: 2. For 50% of specialists, males were estimated to account for 20-40% of their adult cases and for 23%, this increased to an estimated 40-60%. Class II division 1 malocclusion and skeletal II were considered the most common dentofacial characteristics. Occlusal features encountered in decreasing frequency were generalised crowding, increased overjet, deep overbite, late lower incisor crowding, spacing and impacted teeth. Fifteen per cent reported that at least 10% of their adult cases required orthodontics with maxillofacial surgery but 8% reported that this was at least 50%. Treatment challenges commonly acknowledged were overbite reduction, anchorage management, 'black triangles' and overjet reduction. Tooth whitening was reckoned to be used by 19% of specialists. Aesthetic upper and stainless steel lower brackets were indicated to be used most often whereas only 19% used clear aligners and 10% used lingual appliances often.
Conclusions: The profile and characteristics of adults currently undergoing orthodontic treatment in the ROI were diverse. Higher estimates were quoted for self-than for general dental practitioner-referral. A high percentage of treatment was reported to be undertaken for non-professionals and males. A wide range of treatment and varying use of appliance types were cited.


How immigration reform is like ordering a pizza at a house party.
On Monday a group of states brought a suit against the federal government claiming that President Obama’s executive action on immigration would add additional public services, which would increase costs, putting additional burdens on already tight budgets. They put up a convincing enough argument that the judge ruled the Obama administration would have to prove its case before going forward with the order. Not to mention Congress is refusing to fund the Department of Homeland Security (DHS) if the Obama administration doesn’t rescind its executive action. In which DHS’ funding runs out in the next couple of days.
I know, this can get confusing. So to explain this whole situation better, imagine if immigration reform were a pizza.
You’re at this house party where everyone is hungry, so getting a pizza is a great idea! The problem is however no one can decide what toppings to get. So the Obama administration decides to order a half-deportation protection and half-citizenship limitation pizza, sans the 160-mile steel wired-fence crust, because – let’s face it – would be unnecessary and cost extra.
For a while everything looks to be copacetic. Until the pizza guy knocks on the door and the states answer. See the states are kind of like your stoner friends in this scenario. Even though the Obama administration ordered the pizza because they wouldn’t shut-up about it, they don’t want to pay for anything even though everyone knows those motherfuckers are going to be eating the entire thing!
Then you have Congress. Or as everyone knows them as, those guys that like the smell of paste. Even if they can never seem to do anything else other than eat paste, the people at the party keep nominating them to figure out the whole pizza situation. But instead of doing that they were asked to do, they just ended up sitting in the corner and eating paste the whole time.
Now since the Obama administration ordered the pizza, Congress is pissed that they weren’t included in the decision of the pizza toppings, even though both of them know, they were never planning on ordering that fucking thing anyway. Still Congress is so upset that you don’t include them on this, they are threatening to burn down the Department of Homeland Security’s (DHS) house. Granted DHS’ house is pretty shitty to begin with, but all they are doing is just hosting the party. So why is Congress getting them involved? More over doesn’t burning down the whole house seem a little extreme?
Probably because they aren’t the sharpest of kids.
Between the threats of burning down the house and the states not wanting to pay for the pizza, the Obama administration decides to hold-off on the whole pizza idea. The problem is that you still have a house full of people that really need that pizza. Around 3.5 million of them. Until then, the party is more like this…
(Photo Credits: Google Images)


CROWN COUNSEL (Criminal)
The Paralegal performs complex legal assignments and a variety of tasks to support the legal team in establishing a solid foundation for efficient court case management.
The incumbent will be required to provide Corporate Secretarial and Legal Services, manage the provision of Administrative Services, exercise care and diligence in the performance of all assigned responsibilities with the on-going observance of the Board’s standards, policies and procedures.
We are regularly recruiting for corporate/funds Executive Legal Secretaries to join successful global law firms in the Cayman Islands on a contract basis.
ACTING GRAND COURT JUDGES - FINANCIAL SERVICES DIVISION


text:
In 2021–22, 162 of the 211 Commonwealth-funded Indigenous primary health care organisations had a governing committee/board and 91 had all Indigenous members
In 2021–22, 674 corporations with principal activities of health and community services were incorporated under the Corporations (Aboriginal and Torres Strait Islander) Act 2006 (CATSI Act) and registered with the Office of the Registrar of Indigenous Corporations (ORIC)
In 2017–18, 99% (or 195) of the 198 Commonwealth-funded Indigenous primary health care organisations reported having accessible and appropriate client/community feedback mechanisms in place
- The Office of the Registrar of Indigenous Corporations (ORIC) registers and regulates Indigenous corporations according to the Corporations (Aboriginal and Torres Strait Islander) Act 2006 (CATSI Act) and provides support and advice to help them manage their affairs effectively.
- The data show that the majority of Indigenous primary health care providers are demonstrating sound governance arrangements, including planning processes and having a governing committee/board in place.
- In 2021–22, 674 Indigenous corporations that identified as having principal activities of health and community services were incorporated under the CATSI Act and were registered with ORIC. Around 64% (432) of these corporations complied with their obligations to submit annual reports to ORIC.
- In 2021–22,162 of the 211 (77%) Commonwealth-funded Indigenous primary health care organisations reported having a governing committee/board; 91 (56%) had a committee/board who were all Aboriginal and/or Torres Strait Islander people.
- Of the 162 Indigenous primary health care organisations in 2021–22, 79 (49%) of them had governing committee/board members who had received training related to governance issues, 91 (56%) had a committee/board who were all Indigenous Australians, and 69 (43%) had a board that included at least one independent (skill-based) member.
- In 2017–18, 77 of the 79 (97%) Commonwealth-funded organisations providing substance-use services for Indigenous Australians reported having a governing committee/board; 47 (61%) of these had a committee/board who were all Aboriginal and/or Torres Strait Islander people.
- Competent governance also includes participation in planning processes and engagement with community members. In 2017–18, 195 of the 198 (99%) Commonwealth-funded Indigenous primary health care organisations reported having accessible and appropriate client/community feedback mechanisms in place.
- In 2017–18, 97% of Commonwealth-funded Indigenous primary health care organisations participated in organisational planning processes.
- Aspects of good practice by governments to support the governance of Indigenous organisations include long-term contracting, good contract management, risk sharing, working with Indigenous Australians in decision-making, research and evaluation, and simplified data collection, monitoring and information sharing.
Why is it important?
‘Governance’ refers to the evolving processes, relationships, institutions and structures by which a group of people, community or society organise themselves collectively to achieve things that matter to them. Governance enables the representation of the welfare, rights and interests of constituents, the administration and delivery of programs and services, the management of resources, and negotiation with governments and other groups (Hawkes 2001; Hewitt de Alcántara 1998; Westbury 2002). Governance occurs at the community, local, regional and national level. The manner in which governance functions are performed has a direct effect on the wellbeing of individuals and communities.
Competent governance in the context of Indigenous primary health care services ensures the services are effectively and efficiently managed, and that the cultural, social and health needs of Indigenous communities are taken into account. This measure explores the role of competent governance of Indigenous primary health care services in the delivery of care to Aboriginal and Torres Strait Islander people.
Within governance, appropriate consultation and engagement with Indigenous communities in decision-making processes play a vital role in the delivery of primary health care for Indigenous Australians. Community control of health services allows Indigenous Australian communities to determine their own priorities, protocols and procedures. The care these services provide will also reflect the values and principles of the community they serve. It can also help to build trust and accountability, and promote the sustainability of health care services over the long-term.
The Aboriginal Community Controlled Health Services (ACCHSs) model is the main governance model adopted by Indigenous primary health care providers. An ACCHS is an incorporated organisation initiated and based in local Indigenous communities. They deliver a holistic, comprehensive, and culturally appropriate health service to the community. While the capabilities and capacity of ACCHSs vary, this model of care provides important options for Indigenous Australians (Moran et al. 2014).
The Office of the Registrar of Indigenous Corporations (ORIC) administers the Corporations (Aboriginal and Torres Strait Islander) Act 2006 (CATSI Act). The legislation sets out governance standards of Aboriginal and Torres Strait Islander corporations, and provides a governance of framework that is tailored to suit the needs of Indigenous Australians. The ORIC is also responsible for registering and regulating Indigenous corporations, ensuring that they comply with the CATSI Act, and providing support and advice to help them manage their affairs effectively.
In 2021–22, 674 corporations that identified as having principal activities of health and community services were incorporated under the CATSI Act and were registered with ORIC. Of these, 671 were required to submit annual reports to ORIC under the CATSI Act, and 432 (64%) complied with their obligations (Table D3.13.2).
The Online Service Report (OSR) collects organisation-level information from health care organisations funded by the Australian Government’s Indigenous Australians’ Health Programme (IAHP). In the 2021–22 OSR, 162 of the 211 (77%) Commonwealth-funded Indigenous primary health care organisations reported having a governing committee/board (Table D3.13.3).
Of these 162 Indigenous primary health care organisations, 79 (49%) of them had governing committee/board members who had received training related to governance issues, 91 (56%) had a committee/board who were all Indigenous Australians, and 69 (43%) had a board that included at least one independent (skill-based) member (Table D3.13.3, Figure 3.13.1).
Figure 3.13.1: Governing committee/board information for Aboriginal and Torres Strait Islander primary health care organisations, 2021–22
In 2017–18, 77 of the 79 (97%) Commonwealth-funded organisations providing substance-use services for Indigenous Australians reported having a governing committee/board. Of these 77 organisations, 76 (99%) reported that their committee/board had met as frequently as required of the constitution; 77 (100%) had presented income/expenditure reports to the committee/board on at least two occasions during the year; 47 (61%) had a committee/board who were all Aboriginal and/or Torres Strait Islander people; and 64 (83%) had committee/board members who had received training related to governance issues (Table D3.13.4). Collection of these data ceased after the 2017–18 OSR collection, so no updates are available.
Competent governance also includes participation in planning processes and engagement with community members (see measure 3.08 Cultural competency). Of the 198 Commonwealth-funded Indigenous primary health care organisations in the 2017–18 OSR, 195 (99%) reported having accessible and appropriate client/community feedback mechanisms in place (Table D3.08.14); 125 (63%) had representatives on external boards (such as hospitals); 193 (97%) had participated in organisational planning processes; 164 (83%) had participated in regional health planning processes; and 121 (61%) had participated in state/territory or national policy development (Table D3.13.5). Collection of these data ceased after the 2017–18 OSR collection, so no updates are available.
What do research and evaluations tell us?
Research has identified that Indigenous primary health care services (e.g., ACCHSs) outperform mainstream services, as Indigenous primary health care services are often controlled by their local communities and therefore are underpinned by the values and principles of communities they serve. For example:
- 95% of Indigenous primary health care providers had a formal commitment to providing culturally safe health care (AIHW 2019).
- ACCHSs are more likely than mainstream services to improve the health outcomes of Indigenous Australians (Harfield et al. 2018).
- Many Indigenous clients have a preference for services delivered by ACCHSs rather than mainstream services (AH&MRC 2015).
A study comparing the health outcomes for Indigenous Australians using ACCHSs with the outcomes achieved through mainstream services showed that ACCHSs (Panaretto et al. 2014):
- reflect the patient-centred medical home model (Stange et al. 2010)—the suggested best practice for general practice (Claire 2012; DoHA 2009).
- have a greater than 60% coverage of the Indigenous population outside major metropolitan centres.
- consistently improved performance in key best-practice care indicators.
- performs better than mainstream general practice in several areas, including prevention, chronic disease management, risk factor monitoring, and health assessment.
ACCHSs are found to play a significant role in training the medical workforce and employing Indigenous Australians. ACCHSs have also been found to rise to the challenge of delivering best-practice care, and there is a case for expanding ACCHSs into new areas (Panaretto et al. 2014).
Culture has been found to be a fundamental component of the success of Indigenous primary health care service delivery. Culture is critical to ensuring community participation, enabling Indigenous ownership and governance by engaging communities. Culture is also essential in ensuring the approach to care is culturally appropriate, relevant and holistic, such as traditional healing (Harfield et al. 2018).
The Indigenous Community Governance Project by the Centre for Aboriginal Economic Policy Research and Reconciliation Australia has provided academic rigour to the examination of governance practices. The project provides a framework for negotiation between Australian governments, their agents and Indigenous groups over the appropriateness of different governance processes, values and practices, and over the application of related policy, institutional and funding frameworks within Indigenous affairs (Hunt et al. 2008; SCRGSP 2016).
Evaluations and studies of Indigenous reform initiatives have identified aspects of good practice by governments needed to support the governance of Indigenous organisations. These include:
- long-term contracting to build trust, enhance capacity and afford Indigenous organisations sufficient time to operate in a complex environment,
- good contract management to simplify compliance requirements and reduce transaction costs,
- risk sharing and management through clearer communications and reporting lines,
- working with Indigenous Australians to better understand the complex nature of Indigenous affairs, and ensure their voices are heard in decision-making, research and evaluation, and
- simplified data collection, monitoring and information sharing, based on sound performance and health outcome indicators, using a single reporting framework (Dwyer et al. 2009; OIPC 2006; Yu et al. 2008).
An evaluation of a community engagement strategy, applied across five districts in Perth, found that actively engaging Indigenous communities in decisions about their health care resulted in stronger relationships between community members and health services, improved health services that were more culturally appropriate, and increased access to, and trust in services (Durey et al. 2016).
The Institute for Urban Indigenous Health (IUIH) developed a new regional and systematised model—IUIH System of Care—for how primary care is delivered and intersects with the broader health system. The IUIH System of Care facilitates an integrated approach that engages across local, system and community levels. A review of the IUIH System of Care found improvements in outcomes among Indigenous Australian clients, and that there is the capacity to deliver similar improvements in health access and outcomes in other regions (Turner et al. 2019).
The data show that the majority of Indigenous primary health care providers are demonstrating sound governance arrangements, including planning processes and having a governing committee/board in place.
However, there is a lack of data to measure other factors of governance, such as the participation of Indigenous Australians in decision-making (SCRGSP 2016).
Making space for Indigenous Australians to define the issues, determine the priorities and suggest solutions for culturally informed strategies that address local community needs is a way to reduce health inequities and has the potential to influence system changes (Crooks et al. 2020). COVID-19 highlighted the unique capacity of ACCHSs to respond rapidly and effectively in a national health crisis. Well before the pandemic was declared by the World Health Organisation (WHO), the sector had mobilised. It commenced planning locally and advocated nationally for border and community closures, access to testing, personal protection equipment, contact tracing capacity and lockdown measures. The partnership between the National Aboriginal Community Controlled Health Organisation (NACCHO) and the Australian Government was critical in supporting Aboriginal communities across Australia to develop local plans. It built on a pre-existing relationship that had effectively responded to syphilis outbreaks (Department of Health 2021).
A key strength of ACCHSs is their ability to respond flexibly to local community needs. This is a result of broadly defined service provisions connected to grant funding allowing considerable discretion in allocating these funds according to their core governance and organisational priorities. It has been suggested that self-determination has led to the development of health services with complex functions that are often a focal point for the community. However, key challenges include meeting the demands placed on Indigenous health services by their constituents and their funders in the face of geographical and other variable factors impacting commercial viability of activities. The certainty and flexibility of the funding granted to ACCHSs allows them to fund core critical staff (offering continuity) for these health services and covers the central expenses of administration and governance (Moran et al. 2014).
Good and effective governance among services can be facilitated by improved coordination among government agencies in their interaction with services, removing duplication of programs and functions, adapting to change, establishing a stable policy environment and effective processes, and learning from evidence drawn from past evaluations (Henry 2007; SCRGSP 2011).
ORIC is enhancing corporate governance within Indigenous corporations by offering comprehensive two and three-day workshops. These Introduction to Corporate Governance workshops, free to attend for directors, future directors, and members of Aboriginal and Torres Strait Islander corporations registered under the CATSI Act, delve into the foundations of good governance, roles and responsibilities of different corporate positions, financial management, and other pertinent themes. Successful completion of these workshops makes participants eligible for further accredited courses offered by ORIC that aim to continue the development of key personnel within Indigenous corporations.
The policy context is at Policies and strategies.
- AH&MRC (Aboriginal Health & Medical Research Council) 2015. Aboriginal communities improving Aboriginal health: an evidence review on the contribution of Aboriginal Community Controlled Health Services to improving Aboriginal health. Sydney.
- AIHW (Australian Institute of Health and Welfare) 2019. Cultural safety in health care for Indigenous Australians: monitoring framework. Canberra: AIHW.
- Claire LJ 2012. Australian general practice: primed for the "patient-centred medical home". Medical Journal Australia 197:365-6.
Crooks K, Casey D & Ward JS 2020. First Nations peoples leading the way in COVID-19 pandemic planning, response and management. The Medical Journal of Australia 213:151-2.e1.
Department of Health 2021. National Aboriginal and Torres Strait Islander health plan 2021–2031. Government of Australia.
- DoHA (Australian Government Department of Health and Ageing) 2009. Primary Health Care Reform in Australia: Report to Support Australia's First National Primary Health Care Strategy.
- Durey A, McAullay D, Gibson B & Slack-Smith L 2016. Aboriginal Health Worker perceptions of oral health: a qualitative study in Perth, Western Australia. International Journal for Equity in Health 15:4.
- Dwyer J, O'Donnell K, Laviole J, Marlina U & Sullivan P 2009. Overburden Report: Contracting for Indigenous Health Services, The. Overburden Report: Contracting for Indigenous Health Services, The:viii.
Finlay S & Wenitong M 2020. Aboriginal Community Controlled Health Organisations are taking a leading role in COVID-19 health communication. Australian and New Zealand journal of public health 44:251-2.
- Harfield. SG, Davy. C, McArthur. A, Munn. Z, Brown. A & Brown. N 2018. Characteristics of Indigenous primary health care service delivery models: a systemic scoping review. Globalization and Health 14.
- Hawkes DC 2001. Indigenous peoples: self-government and intergovernmental relations. International Social Science Journal 53:153-61.
- Henry K 2007. Creating the right incentives for Indigenous development. The Treasury.
- Hewitt de Alcántara C 1998. Uses and abuses of the concept of governance. International Social Science Journal 50:105-13.
- Hunt J, Smith D, Garling S & Sanders W 2008. Contested governance : culture, power and institutions in indigenous Australia. Canberra: CAEPR.
- Moran M, Porter D & Curth-Bibb J 2014. Funding Indigenous organisations: improving governance performance through innovations in public finance management in remote Australia. (ed., Australian Institute of Health and Welfare). Canberra: Closing the Gap Clearinghouse.
- OIPC (Office of Indigenous Policy Coordination) 2006. A Red Tape Evaluation in Selected Indigenous Communities: A report by Morgan Disney Associates. Canberra , ACT.
- Panaretto KS, Wenitong M, Button S & Ring IT 2014. Aboriginal community controlled health services: leading the way in primary care. The Medical Journal of Australia 200:649-52.
- SCRGSP (Steering Committee for the Review of Government Services Provision) 2011. Overcoming Indigenous disadvantage: Key indicators 2011. Canberra, Productivity Commission (Steering Committee for the Review of Government Service Provision).
- SCRGSP 2016. Overcoming Indigenous Disadvantage: Key Indicators 2016. Canberra: Productivity Commission.
- Stange KC, Nutting PA, Miller WL, Jaén CR, Crabtree BF, Flocke SA et al. 2010. Defining and measuring the patient-centered medical home. J Gen Intern Med 25.
- Turner LR, Albers T, Carson A, Nelson C, Brown RB & Serghi M 2019. Building a regional health ecosystem: a case study of the Institute for Urban Indigenous Health and its System of Care. Australian journal of primary health.
- Westbury ND 2002. The importance of Indigenous governance and its relationship to social and economic development. Unpublished Background Issues Paper produced for Reconciliation Australia. Canberra.
- Yu P, Duncan ME & Gray B 2008. Northern Territory Emergency Response: Report of the NTER Review Board. (ed., Government A).


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We are excited to report two University of Phoenix teams presented at the Small Business Institute 2021 Annual Conference (virtual) on February 25-26, 2021.
Career and Technical Education in COVID-19: A New Beginning?
Team: Irene Chen, Elizabeth Isele, Matt Knight, Ronald Leach, Norris Krueger, Jean Perlman, Louise Underdahl
Economic, political, social, academic, public health, and philosophical dimensions of COVID-19 have catalyzed career and technical education (CTE) innovation. Risks and uncertainties associated with COVID-19 are complemented by unprecedented educational opportunity, progress, and new beginnings. This multiple case study highlights novel approaches to accelerating CTE development, experiential learning, pedagogy, and entrepreneurship in the COVID-19 environment.
Reframing Start-Up Success: Action Learning and Beyond
Team: Wendy van Schalkwyk, Herman van Niekerk, Louise Underdahl
Reframing start-up success synthesizes real life start-up entrepreneurship outcomes with education curricula, integrating theory and practice in a safe learning and personal growth environment. Action Learning is the pedagogical foundation upon which to build and sustain academic/community/industry partnerships. This study contributes to existing literature and presents Action Learning as a system-based approach which incorporates all the elements of a learning ecosystem in a holistic manner for consideration by economic, social, political, and academic policymakers.

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In December 2013, on Wukang Road and Yuqing Road in Shanghai, residents experienced an autumn street scene with fallen leaves. Since these experimental street scenes were implemented, many photographers and tourists have come to visit these streets, and the number of visitors to the area has increased more than 40%, compared with the number last year.
Now the street sweepers have resumed their normal routine, and the street scenes with fallen leaves have disappeared. However, the debate over whether to continue this street scene next year and promote this practice to other streets continues.
Surveys done by the Shanghai Xuhui District’s Landscape and Beautifying Department showed that nearly 80% of residents supported the practice, since they liked the romantic feeling of fall created by nature. According to resident Mr. Zhang, in December, he wandered on the two streets almost everyday. Many residents suggested having fallen leaves on more streets in the coming years. However, there is also an opposing voice to this policy. Another resident, Mr. Lu said that he uses an electric car to go to work everyday, and it was unsafe to drive on the leaves.
According to Wu Zhixing, senior engineer from the Shanghai Landscaping Institute, whether or not to leave the fallen leaves on the streets should be a flexible policy depending on the location and time. Shanghai University sociology professor Gu Jun said that tourists prefer visiting attractions that look natural.
According to staff from the Shanghai Xuhui District’s Landscape and Beautifying Department, this was the first year that Xuhui District tried out the fallen leaves street scene. Based on the feedback from the residents, the district will continue this practice next year, but they have not decided whether to promote this policy to other streets.
How does the city you live in deal with fallen leaves on the streets?
Credits: Images and data linked to sources.
The original article, published in Chinese, can be found here.


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Stephen Fry's Greek myths volume 2
In this continuation of "Mythos," Stephen Fry recounts the stories of the human heroes found in Greek mythology, with illustrations of classical art inspired by the myths.
"The classic stories from Greek mythology come to life in this latest installment in the Weird But True Know-It-All series, featuring Zeus, Hades, Athena, Poseidon, Artemis, Heracles, Prometheus, and many more! From the god who gave mankind fire, to who stood guard at the Underworld, to famous fatal flaws, this book covers all the iconic Greek myths and key character--along with wonderfully weird and surprising tidbits"--Back cover.
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A corrupt former aide to Gov. Cuomo was ordered Friday to report to federal prison March 1.
Joseph Percoco lost his argument that he should be free on bail pending appeal. Manhattan federal Judge Valerie Caproni said in a 54-page decision that Percoco must begin his sentence because his appeal did not raise a “substantial question of law or fact.”
Caproni rejected Percoco’s arguments that he should remain out on bail pending appeal, writing in a 54-page decision that his case did not raise a “substantial question of law or fact.”
Percoco was convicted of accepting over $300,000 in bribes, which he referred to as “ziti.” The money came from two upstate businesses — a Hudson Valley energy firm, Competitive Power Ventures, and a Syracuse real estate developer, COR Development.
Steve Aiello, the former president of COR Development, must also start serving his sentence on the same day, Caproni wrote. Aiello was convicted of bribery conspiracy and other charges in the case.
Percoco, 49, was one of Cuomo’s closest friends and wielded major influence in Albany. As the governor’s executive deputy secretary, he implemented Cuomo’s agenda and oversaw logistics of critical initiatives.
Publicly, Cuomo did not rue Percoco’s conviction. “The rule of law is paramount,” Cuomo said in a statement after he was sentenced. “Joe Percoco is paying the price for violating the public trust.”
A message to Percoco’s attorney was not returned.


Wind turbines are not a new thing but they’re gaining popularity and are being used as a primary source in certain countries to create new electrical energy from renewable sources, such as the wind.
While wind turbines are simple to build and get in function on paper, there’s much more to them than it meets the eye.
Not many are aware that wind turbines get help from slip rings to provide smooth operation, and while slip rings are a small and often overlooked device, they play an important role in wind turbines.
And that’s exactly what you’ll learn about down below, so keep on reading!
How do Wind Turbines Work and What is Their Purpose?
Wind turbines are built to “harvest” the wind which is an unlimited and renewable source that can be used to produce energy.
That’s why wind turbines come with large blades that get rotated with the help of the wind. Upon the rotation of the blades, the wind turbine’s rotor spins.
Since the rotor is connected to the main shaft of the wind turbine, it helps to spin a generator which is actually the component that creates new electricity.
With wise placements of wind turbines, they can help create electrical energy from a renewable source that is positive for the environment and is actually an affordable solution, regardless of the high manufacturing and installation price of one wind turbine.
Therefore, with the main purpose being to produce new electricity without wasting any non-renewable sources on the Earth, wind turbines can produce cost-effective electricity that can generate power for the local population, create more jobs, can be used as a clean fuel source (electric vehicles), and is very sustainable.
Use of Slip Rings in Wind Turbines
While many know that wind turbines consist of a blade, the main shaft, a rotor, and a generator that does the whole work, not many know that wind turbines also depend on smaller devices such as slip rings.
Slip rings are small and compact devices that have more than one purpose. The main purpose is to provide a smooth operation between a stationary and rotational part of a machine.
In the case of wind turbines, slip rings act as a joint between the blades and the rotor, providing a connection, which further goes onto the generator.
There are actually a couple of slip rings placed in wind turbines and they can be found in the blades, and at the connecting points between the blades and the rotor.
These slip rings actually don’t only bridge the gap between the different parts of a wind turbine, but they’re also very crucial and are responsible for wind generator’s power, and on top of that, transmission of signal and data.
They provide precision that’s required for a power generation system, which is as important as main components such as the blades, rotator, the shaft, and the generator.
There are specific slip rings for wind turbines and companies such as Moflon have wind turbine slip rings. Moflon produces a wide range of wind turbine slip rings with various power ring and wind turbine specifications.
Would Wind Turbines Work Without Slip Rings?
With so many moving and rotating parts in a wind turbine, it would be impossible for it to work without a slip ring.
Slip rings are crucial in wind turbines because they don’t only help combine and bridge the gap between rotor blades and the rotor, which then leads the transmission onto the shaft. Yet slip rings are also important for a generator in the wind turbine that actually produces electricity.
Slip ring helps provide power as well as data and signal all the way from the top of the wind turbine down to the bottom (to the generator).
Also, slip rings are used to ensure wind turbines don’t spin too fast (as a limitator) to eliminate hazards since wind turbines are made to “harvest” the wind, but too much wind without slip rings to control the maximum rotating speed of the blades would cause problems.
Moflon is a company that produces slip rings specifically for wind turbine use and they’re called the MF series. Moflons’ wind turbine slip rings are specifically designed to provide transmission of power and signal all the way from nacelle to the system for control of the rotary blades.
Their slip rings are also reinforced and robust to withstand the most demanding conditions of wind turbines so they ensure the least down time possible to cut down any potential loss.
Environmental Benefits of Wind Turbines for the World
The biggest benefit of wind turbines is that they use renewable source, the wind, to produce electric energy from nothing but the wind.
They work as a reversed fan, instead of using any non-renewable source to produce electric energy, they rely only on wind.
With that being said, wind turbines cut down the amount of electricity that is made from other sources, such as fossil fuels. It’s a chain that leads to less air pollution and less CO2 emissions.
Therefore, wind power is very cost effective, it can also be used to produce clean fuel source for electric vehicles, for example, and it’s highly sustainable since one wind turbine has a lifespan of about 20 years.
All of these benefits work together to provide industry growth and it can even create jobs so it’s also good for the economy, not just for the environment.
Wind turbines are very simple on paper and are highly sustainable, and even though they cost a lot to manufacture and install, the benefits bring a lot of value, not only to the environment, but also to the economy.
Even though slip rings are a small device, they play a huge part in the operation of a wind turbine, more than people often realize.
Without them, wind turbines wouldn’t function at all or even if they did, they wouldn’t be half as efficient as they are now.
But environmental benefits are definitely worth the possible downsides of wind turbines, and yet it’s really great to see that wind turbines are increasing in popularity and are getting huge improvements that lead to better results.
Article Submitted By Community Writer