EAACI taskforce position paper: evidence for autoimmune urticaria and proposal for defining diagnostic criteria

An autoimmune subset of chronic spontaneous urticaria is increasingly being recognized internationally, based on laboratory and clinical evidence that has accrued over the last 20 years. This evidence has been reviewed by a taskforce of the Dermatology section of the European Academy of Allergy and Clinical Immunology. Functional autoantibodies in chronic urticaria (CU) patient sera have been demonstrated against IgE and FcεRIα by basophil and mast cell histamine release assays and by basophil activation assays. Antibody specificity has been confirmed by immunoassay, but there is a poor correlation between functionality and immunoreactivity. Approximately 25% of CU patients have a positive basophil histamine release assay and show autoreactivity (a positive autologous serum skin test), whereas 50% are negative regarding both. Functionality of CU sera appears to be complement dependent on mast cells but not exclusively on basophils. Basophil activation by CU sera is predominantly restricted to IgG1 and IgG3 subclasses. Circumstantial evidence for CU being an autoimmune disease comes from an observed association with other autoimmune diseases, a strong association between serum functionality and HLA-DR4 haplotype and the good response of CU patients to immunotherapies. It was proposed that a study should be undertaken to prospectively validate potentially relevant clinical criteria (from the history, examination and routinely available clinical investigations) against a new 'gold standard' for the diagnosis of ACU (positive autoreactivity, functional bioassay and immunoassay) to define preliminary criteria sets for the diagnosis of ACU based on clinical and laboratory features with highest individual sensitivity and specificity.

Abstract P6-12-03: Effects of high dose of bisphosphonate therapy on bone microarchitecture of the peripheral skeleton in women with early stage breast cancer

Background: Randomized studies investigating adjuvant bisphosphonates in women with breast cancer are ongoing. While bisphosphonates would be expected to prevent the deterioration of bone microarchitecture that accompanies hormone or chemotherapy, complete suppression of osteoclast activity for prolonged periods of time can decrease repair of micro-cracks, and possibly lead to decreased bone strength. While bone strength is governed by the amount of bone present, trabecular and cortical components of bone microarchitecture also contribute independently to bone strength. We aimed to characterize the effects of long-term bisphosphonates on bone microarchitecture in women with breast cancer using high-resolution peripheral quantitative computed tomography (HR-pQCT) of the distal radius and tibia.

Methods: We conducted a cross-sectional study involving early stage breast cancer patients treated with bisphosphonates on the S0307 clinical trial. Women were randomized to receive zoledronic acid, oral clodronate or oral ibandronate in doses far higher than those used in osteoporosis treatment as per protocol. After 18–36 months of bisphosphonate therapy, participates underwent a one-time evaluation of areal bone mineral density (aBMD) of the 1/3 radius, lumbar spine, and hip by dual energy x-ray absorptiometry (DXA), and cortical and trabecular volumetric BMD (vBMD) and trabecular microarchitecture of the radius and tibia by HR-pQCT. HR-pQCT measurements were compared to healthy young premenopausal women and age-matched Caucasian women.

Results: Baseline characteristics of the 12 enrolled patients: median age of 53 (range 40–67); white/Hispanics 7/5; pre/postmenopausal 4/8; mean body mass index 28.7 kg/m2 (20.9–34.8); average time on bisphosphonates 20 months (18–30); zoledronic acid/clodronate/ibandronate 5/6/1. The median aBMD DXA T-score of the 1/3 radius, lumbar spine and total hip were normal at +0.3, +0.1, and +0.2, respectively. Mean total, cortical, and trabecular vBMD of the radius as measured by HR-pQCT were 330±71, 905±55, and 146±35 mg hydroxyapatite/cm3, respectively. Mean cortical thickness was 0.803±0.170 mm, and mean trabecular number was 1.9±0.2. Mean total, cortical, and trabecular vBMD of the tibia were 285±54, 880±54, and 150±38 mg hydroxyapatite/cm3, respectively. Mean cortical thickness was 1.135±0.264 mm, and mean trabecular number was 1.7±0.3. There were no statistically significant differences between study group and each control. However, results were more similar to healthy young premenopausal control than the age-matched control.

Conclusion: Women on long-term bisphosphonate therapy for breast cancer had normal aBMD by DXA and normal cortical and trabecular vBMD, cortical thickness and trabecular number at the peripheral skeleton compared to healthy young women and age-matched women. This preliminary data is reassuring for cancer survivors if benefits from this therapy are established in the adjuvant setting.

Abstract P2-11-03: Randomized, single blind trial comparing limited and intensive survivorship interventions following adjuvant therapy in a multiethnic cohort of breast cancer survivors

Background: In 2005, the Institute of Medicine released a report citing the importance of comprehensive treatment summaries or “survivorship plans” for cancer patients completing adjuvant therapy. However, little is known about the best approach or the impact of these interventions on patient well-being. We compared quality of life, treatment satisfaction and cancer impact measures between a minimal or more intensive intervention.

Methods: The study was conducted at a single-institution academic breast cancer practice. Women with non-metastatic breast cancer were randomized within six weeks of completing adjuvant therapy (chemotherapy/radiation therapy) to a minimal intervention group (MG) or intensive intervention group (IG). The MG group was given the NCI publication, “Facing Forward: Life after Cancer Treatment” by lay research staff. The intensive group received the same NCI publication; met in person for 1 hour with a nurse practitioner who provided a treatment summary, surveillance and screening recommendations, and information on risk for late effects; and met in person for 1 hour with a nutritionist to review lifestyle recommendations. Subjects were informed that they were in a study of cancer survivors but unaware they were being randomized. The randomization was stratified by ethnicity (Hispanic/non-Hispanic). Both groups completed the 81-item impact of cancer instrument (IOC), functional assessment of chronic illness therapy-treatment satisfaction-patient satisfaction questionnaire (FACIT-TS-PS) and assessment of survivor concerns (AOC) at baseline, 3 and 6 months. Group t-tests and between group linear regression analyses were performed controlling for ethnicity.

Results: Of 140 patients who signed consent, 126 women (66 non-Hispanic, 60 Hispanic) completed baseline questionnaires, 109 completed 3 month, and 109 completed 6 month assessments. The groups were well balanced with regard to age (mean = 54), race, marital status, income and employment status. There were no statistically significant differences between the MG and IG on the 8 domains that comprise the FACIT-TS-PS at 3 and 6 months. The health worry scale of the AOC was lower in the IG (p = 0.006) compared to MG, indicating less health worry and the negative outlook score of the IOC was higher in the MG (p = 0.043) compared to IG at 3 months. At baseline, 3 and 6 months, Hispanic women compared to non-Hispanic women had significantly higher (worse) ACS and IOC health worry (p < 0.001), social life interference (p = 0.01) and meaning of cancer scales (p = 0.0004), but also had greater trust in medical professionals (p = 0.029).

Conclusions: We did not observe a difference in most of the IOC or treatment satisfaction scores between the MG and IG interventions at 3 or 6 months, nor did we find any significant change from baseline in either group. However, less health worry and less negative outlook were seen in the IG compared to the MG. At baseline and follow-up, Hispanic women in both interventions compared to non-Hispanic women had more extreme scores on most measures. Despite minimal difference between the interventions, the intensive intervention was more time-consuming and used more health care resources.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-11-03.

Abstract P1-09-02: Pilot study of a 1-year intervention of high-dose vitamin D in women at high risk for breast cancer

Background: Selective estrogen receptor modulators (SERMs) have been shown to decrease breast cancer incidence among high-risk women, but uptake for prevention has been poor. Observational studies have demonstrated that serum 25-hydroxyvitamin D (25-OHD) is inversely related to breast cancer risk, such that levels >40 ng/ml are associated with about a 40% reduction in breast cancer risk compared to women who are vitamin D deficient (25-OHD <20 ng/ml). Uncertainty remains about whether vitamin D supplementation will reduce breast cancer risk, the optimal dose of vitamin D, and the target level of serum 25-OHD. We examined the safety of high dose vitamin D and the effects on serum 25-OHD in women at high risk for breast cancer.

Methods: Forty high-risk women (defined as a 5-year Gail risk ³1.67%, lobular or ductal carcinoma in situ [LCIS/DCIS], BRCA1/BRCA2 mutation carrier, or stage I/II invasive breast cancer in remission for >5 years) were assigned to a 1-year intervention of vitamin D3 20,000 or 30,000 IU weekly. Other eligibility criteria included baseline mammographic density (MD) ≥25%, serum 25-OHD ≤32 ng/ml, no current SERM use and no history of kidney stones. Women underwent a digital mammogram at baseline and 12 months, and serial blood draws every 3 months. In addition, random core breast biopsies were conducted in premenopausal women, whereas postmenopausal women underwent a breast MRI at baseline and 12 months. Participants were monitored for toxicity, particularly hypercalcemia and hypercalciuria, every 3 months. The primary objective is to determine the safety and feasibility of high-dose vitamin D in this study population. Secondary objectives are to determine changes in breast density and blood-based biomarkers (25-OHD, 1,25(OH)D, PTH, IGF-I, IGFBP-3). Serum 25-OHD was measured by Diasorin radioimmunoassay.

Results: From November 2007 to January 2011, 292 women were screened and 142 were ineligible. Main reasons for ineligibility (%) included 25-OHD >32 ng/ml (27), opted for SERM (23), prior kidney stones (11), and MD <25% (9). Of the 40 enrolled participants: median age 50 years (range, 37–73); pre/postmenopausal: 20/20; white/hispanic/black/asian: 19/14/6/1; median body mass index 26.6 kg/m2 (20–39.6); elevated Gail risk/LCIS/DCIS/stage I or II breast cancer: 20/10/8/2; mean baseline serum 25-OHD 20.2 ng/ml (9–31). Currently, 1 participant is on-study, 31 completed the intervention, 6 were lost to follow-up, 1 withdrew due to hypercalciuria (spot urine Ca/Cr >0.37) and 1 withdrew due to dyspepsia. Mean serum 25-OHD rose to 47 ng/ml at 3 months, 49.1 ng/ml at 6 months, and 53.7 ng/ml (range, 26–77) at 12 months. No significant hypercalcemia (serum Ca >10.5 mg/dl) occurred at either dose level. Imaging and biomarker analyses are ongoing.

Discussion: We have demonstrated that a 1-year intervention of high-dose vitamin D3 is well tolerated and can increase serum 25-OHD above a target level of 40 ng/ml. This preliminary data has informed an ongoing phase IIb randomized placebo-controlled trial (SWOG 0812) of high-dose vitamin D in 200 high-risk premenopausal women and highlights the importance of early phase breast cancer chemoprevention trials with intermediate biomarker endpoints to test novel agents.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-09-02.

Abstract PD03-03: Pre-surgical Trial of Metformin in Overweight and Obese, Multi-ethnic Patients with Newly Diagnosed Breast Cancer

Background: Overweight or obese women with breast cancer (BC) have a higher risk of distant recurrence and death compared to normal weight women. There is increasing evidence that insulin significantly mediates these adverse clinical outcomes. Laboratory and population studies demonstrate that metformin offers a protective BC effect through reduction of serum insulin levels and direct modulation of cellular protein synthesis and growth through AMPK pathway signaling. Our aim is to assess the biologic impact of metformin on blood- and tumor-based markers on insulin, IGF and AMPK/mTOR pathway signaling, and/or proliferation in operable BC patients with a body mass index (BMI) ≥ 25 kg/m2.

Methods: The study was an open-label pre-surgical trial with metformin 1500 mg PO per day (500 mg am/1000 mg pm) for 2–4 weeks prior to surgical resection in 35 overweight or obese patients with invasive BC (n = 25) or ductal carcinoma in situ (n = 10) and no history of diabetes. The primary endpoint was to assess a reduction in tumor proliferation. We have 80% power to detect a 30% decrease in Ki-67 in invasive BCs from baseline to post-metformin values (two-sample t-test, 0.05). Secondary endpoints include changes in BMI and insulin resistance markers, such as fasting serum insulin, lipid panel, glucose, leptin, and adiponectin. Tumor markers will be compared to untreated historical controls matched by age, BMI, and tumor characteristics.

Results: Between Oct 2009 to Aug 2011, we screened 116 patients, enrolling 35 with newly diagnosed BC: 18/34 overweight (27.6: 25.1–29.7) and 16/34 obese (35.9: 30.5–46.4). Hispanic women made up 80% of the population (28/35). The median metformin duration was 22 days (1–64). All took metformin until the evening prior to surgery, except 2 (1 withdrew and 1 stopped early after surgery delay). More than half had a prior diagnosis of hypertension and a third had hypercholesterolemia. In the invasive BC cohort (n = 25), 19/25 (76%) were HR+/HER2−. The most common grade I-II included self-limiting diarrhea, flatulence, abdominal pain, fatigue, and anorexia. Grade III events included abdominal pain (n = 1) and diarrhea (n = 3). The change in blood markers are described in the table. Tumor Ki-67 (immunohistochemistry) and pathway signaling analyses (reverse protein microarray) are ongoing.

Abstract P4-02-07: Early Optical Tomography Changes Predict Breast Cancer Response to Neoadjuvant Chemotherapy

Background: Pathologic complete response (pCR) or a low Residual Cancer Burden (RCB) score following neoadjuvant chemotherapy (NACT) predicts a superior survival in breast cancer (BC) patients. An early predictive marker of tumor response during NACT would provide a way to optimize treatment for non-responders; however, no ideal technology currently exists. Diffuse optical tomography (DOT) is a novel, fast, safe, and low-cost technique that uses near infrared light to provide 3D data on tissue vascularity without the use of radiation, making it a promising technology for assessing early tumor response to NACT. We hypothesized that a 2-week change in DOT parameters would predict response to NACT as measured by the RCB score.

Methods: Women with stage II-IIIc invasive BC scheduled to undergo NACT with 12 cycles of a weekly taxane followed by 4 cycles of doxorubicin with cyclophosphamide (AC) were enrolled. Treatment with additional biologic therapies was allowed. DOT measurements were made before starting NACT, 2 weeks into treatment, and before surgery. Concentrations of oxyhemoglobin [HbO2], deoxyhemoglobin [Hb], total hemoglobin [HbT], and tissue scattering (SC) were measured by DOT. Final pathology specimens were scored for the RCB index (continuous measure), RCB class (0, 1, 2, 3), and a dichotomized RCB score (RCB class 0 or 1: responders to NACT; RCB class 2 or 3: non-responders). Correlation analysis, ANOVA testing, and two sample t-tests were used to evaluate the relationship between the two-week changes in DOT parameters and the RCB score.

Results: Since July 2011, we have recruited 11 pts, of whom 7 have undergone surgery. Complete data is available for 6 pts. Two of 7 pts had a pCR (RCB 0), 1 had RCB 1, 3 had RCB 2, and 1 had RCB 3. The Pearson correlation between the 2-week change in [Hb] and the continuous RCB index was 0.94 (p = 0.0047), and that between the 2-week change in SC and the RCB index was 0.93 (p = 0.0073). At 2 weeks, the [Hb] decreased by 6.7% for pts whose pathology demonstrated an RCB 0 (pCR), 1.8% for RCB 1, 0.6% for RCB 2, and increased 0.7% for RCB 3. ANOVA and Tukey testing demonstrated a significant difference in the [Hb] change for pts with RCB 0 compared to pts with RCB 1, 2, or 3 (p <0.05). At 2 weeks, SC decreased by 26.5% for pts with RCB 0, 19.3% for RCB 1, 3.7% for RCB 2, and increased by 25.1% for RCB 3. There was a significant difference in the SC change for pts with RCB 0 compared to pts with RCB 3 (p <0.05). Responders (RCB 0/1) had a 5% decrease in [Hb] at 2 weeks compared to non-responders (RCB 2/3) who had a decrease in 0.18% in [Hb] (p = 0.0045), and responders had a 24% decrease in SC compared to non-responders who had an increase in 6% (p = 0.044).

Conclusions: DOT change is an early predictor of response to NACT as measured by the RCB score. We found a significant linear association between the RCB index and the 2-week change in [Hb] and SC. Significantly different changes in DOT parameters were associated with the other RCB classifications. Additional recruitment is ongoing and differences by tumor subtype will be evaluated.

*These two authors contributed equally to this study

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-02-07.

How not to miss autoinflammatory diseases masquerading as urticaria

Urticarial skin reactions are one of the most frequent problems seen by allergists and clinical immunologists in daily practice. The most common reason for recurrent wheals is spontaneous urticaria. There are, however, several less common diseases that present with urticarial rash, such as urticarial vasculitis and autoinflammatory disorders. The latter include cryopyrin-associated periodic syndrome and Schnitzler's syndrome, both rare and disabling conditions mediated by increased interleukin-1 secretion. Apart from the urticarial rash, patients are suffering from a variety of systemic symptoms including recurrent fever attacks, arthralgia or arthritis and fatigue. Autoinflammatory diseases are often associated with a diagnostic delay of many years and do not respond to antihistamines and other treatments of urticaria. Also, the chronic inflammation may lead to long-term complications such as amyloidosis. It is therefore important not to miss these diseases when diagnosing and treating patients with chronic recurrent urticarial rash. Here, we present clinical clues and tips that can help to identify autoinflammatory disorders in patients presenting with chronic urticarial rash and discuss their clinical picture and management.

Allergic Rhinitis and its Impact on Asthma (ARIA): achievements in 10 years and future needs

Allergic rhinitis (AR) and asthma represent global health problems for all age groups. Asthma and rhinitis frequently coexist in the same subjects. Allergic Rhinitis and its Impact on Asthma (ARIA) was initiated during a World Health Organization workshop in 1999 (published in 2001). ARIA has reclassified AR as mild/moderate-severe and intermittent/persistent. This classification closely reflects patients' needs and underlines the close relationship between rhinitis and asthma. Patients, clinicians, and other health care professionals are confronted with various treatment choices for the management of AR. This contributes to considerable variation in clinical practice, and worldwide, patients, clinicians, and other health care professionals are faced with uncertainty about the relative merits and downsides of the various treatment options. In its 2010 Revision, ARIA developed clinical practice guidelines for the management of AR and asthma comorbidities based on the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system. ARIA is disseminated and implemented in more than 50 countries of the world. Ten years after the publication of the ARIA World Health Organization workshop report, it is important to make a summary of its achievements and identify the still unmet clinical, research, and implementation needs to strengthen the 2011 European Union Priority on allergy and asthma in children.

Development and construct validation of the angioedema quality of life questionnaire

BACKGROUND

Recurrent angioedema is a frequent clinical problem characterized by unpredictably and rapidly occurring cutaneous and mucosal swellings. These swellings may be painful and/or disfiguring. Upper airway involvement can also lead to dyspnea and suffocation. Although the disease burden is high, there is currently no specific instrument to measure health-related quality of life (QoL) impairment.

OBJECTIVE

To develop and validate the first symptom-specific tool to assess QoL impairment in recurrent angioedema patients, adhering to established methodological recommendations.

METHODS

During the development phase, 29 questions (items) were generated. Subsequently, item reduction was performed by means of impact analysis and factor analysis as well as by checking for content and face validity. As a result, 17 items were selected and included in the final instrument, the Angioedema QoL Questionnaire (AE-QoL). AE-QoL was then tested for its validity, reliability, and influence factors.

RESULTS

One hundred and ten angioedema patients took part in the validation of AE-QoL. AE-QoL was found to have a four-dimensional structure as well as a valid total score. All of its four domains (functioning, fatigue/mood, fears/shame, food) showed good levels of internal consistency with Cronbach's alpha > 0.8. Test-retesting revealed a good reliability of the instruments total score and domain scores. Gender as well as the patients' self-rated disease activity was found to be predictors of the AE-QoL total score.

CONCLUSIONS

Angioedema Quality of Life Questionnaire is the first angioedema-specific QoL questionnaire. It is a short, valid and reliable instrument that may serve as a valuable tool in future clinical studies and in routine patient care.

Growth, Characterization and Magnetic Properties Of HCP Fe/Ru Superlattices Synthetized by MBE

Hexagonal-close-packed Fex/Rux superlattices with the modulation along the (0001) axis, contaln fully hcp Fe layers. The interatomic Fe-Fe distances are enlarged by about 10% as compared to fcc Fe. Ferromagnetic behavior is found when Fe layers are thicker than about 4 monolayers.

Randomized, double-blind, placebo-controlled study of safety and efficacy of miltefosine in antihistamine-resistant chronic spontaneous urticaria

BACKGROUND

Chronic spontaneous urticaria (CSU), a mast cell-driven condition, is debilitating, common, and hard to treat. Miltefosine, a lipid raft modulator, can inhibit mast cell responses in vivo.

OBJECTIVE

To study the safety and efficacy of systemic miltefosine treatment in CSU patients resistant to standard-dosed antihistamines.

METHODS

In this investigator-initiated multicentre, randomized, double-blind, placebo-controlled study, CSU patients were treated for 4 weeks with daily doses of up to 150-mg miltefosine (n = 47) or placebo (n = 26). Disease activity was assessed using the urticaria activity score. Safety and tolerability of miltefosine were also assessed.

RESULTS

After 4 weeks of treatment, Urticaria Activity Score (UAS7) levels were substantially more reduced in miltefosine-treated patients (-6.3 vs. -3.5 in placebo-treated patients; P = 0.05). Also, the number of weals, but not the intensity of pruritus, was significantly reduced in miltefosine-treated patients vs. placebo-treated patients (P = 0.02). In general, adverse events were frequent in both groups (miltefosine: 88%, placebo: 65% of patients) but mostly mild to moderate in severity. We did not observe any serious adverse events.

CONCLUSIONS

The results of this study indicate that miltefosine is an effective and safe treatment option for CSU patients who do not respond to standard-dosed antihistamines.

Severe chronic allergic (and related) diseases: a uniform approach--a MeDALL--GA2LEN--ARIA position paper

Concepts of disease severity, activity, control and responsiveness to treatment are linked but different. Severity refers to the loss of function of the organs induced by the disease process or to the occurrence of severe acute exacerbations. Severity may vary over time and needs regular follow-up. Control is the degree to which therapy goals are currently met. These concepts have evolved over time for asthma in guidelines, task forces or consensus meetings. The aim of this paper is to generalize the approach of the uniform definition of severe asthma presented to WHO for chronic allergic and associated diseases (rhinitis, chronic rhinosinusitis, chronic urticaria and atopic dermatitis) in order to have a uniform definition of severity, control and risk, usable in most situations. It is based on the appropriate diagnosis, availability and accessibility of treatments, treatment responsiveness and associated factors such as comorbidities and risk factors. This uniform definition will allow a better definition of the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes, education and the discovery of novel therapies.

Critical temperature threshold measurement for cold urticaria: a randomized controlled trial of H(1) -antihistamine dose escalation

BACKGROUND

Cold urticaria is a rare but severe and potentially lethal condition. It is primarily treated symptomatically with H(1) -antihistamines. However, patients have a variable response to these drugs and, to date, it has not been possible to predict readily the response to therapy of individual patients.

OBJECTIVES

To assess the severity of the cold urticaria in naive patients and the response to therapy of patients treated with increasing doses of an H(1) -antihistamine by measurement of critical temperature thresholds (CTT) for producing weals on the forearm.

METHODS

This was a two-centre, hospital-based, double-blind, randomized, parallel-group study of patients with a confirmed diagnosis of cold urticaria of at least 6 months' duration. Patient groups received either a constant dose of desloratadine 5 mg daily for 6 weeks (n = 13), or escalating doses of desloratadine: 5 mg daily for the first 2 weeks, 10 mg daily for the second 2 weeks and 20 mg daily for the final 2 weeks (n = 15). Only one adverse event that appeared to be drug related was reported: mild fatigue after treatment with desloratadine 10 mg that lasted for about 3 weeks and resolved at the end of the study.

RESULTS

The desloratadine 5 mg daily dose produced a submaximal reduction of mean CTT which remained relatively constant over 6 weeks. Dose escalation increased efficacy, the reduction in mean CTT at four-times the standard daily dose being significantly greater (P = 0·03) than with the standard dose. Individually, no patient became symptom free (CTT < 4 °C) on 5 mg, while two became symptom free on 10 mg and a further three on 20 mg desloratadine daily.

CONCLUSIONS

Measurement of CTT allows for individualized risk management and therapy in patients with cold urticaria.

[Childhood-onset mastocytosis]

Mastocytoses are a group of rare diseases characterized, in most cases, by a benign proliferation and accumulation of mast cells in different tissues. In children, mastocytosis affects usually exclusively the skin and differs in many aspects from adult-onset mastocytosis. Except for diffuse cutaneous mastocytosis, which is an uncommon subtype of childhood-onset mastocytosis, involvement of the bone marrow or additional extracutaneous organs is rarely seen in children. The prognosis of childhood-onset mastocytosis is usually very good. Compared to adult patients who most commonly experience chronic-stable or slowly progressive disease, mastocytosis in children is mostly transient and self-limiting. In this review, we present and discuss the subtypes of childhood-onset mastocytosis, recent advances in the understanding of their pathogenesis as well as similarities and differences between adult- and childhood-onset mastocytosis.

Efficacy and safety of the interleukin-1 antagonist rilonacept in Schnitzler syndrome: an open-label study

BACKGROUND

Schnitzler syndrome (SchS) is a rare disease with suspected autoinflammatory background that shares several clinical symptoms, including urticarial rash, fever episodes, arthralgia, and bone and muscle pain with cryopyrin-associated periodic syndromes (CAPS). Cryopyrin-associated periodic syndromes respond to treatment with interleukin-1 antagonists, and single case reports of Schnitzler syndrome have shown improvement following treatment with the interleukin-1 blocker anakinra. This study evaluated the effects of the interleukin-1 antagonist rilonacept on the clinical signs and symptoms of SchS.

METHODS

Eight patients with SchS were included in this prospective, single-center, open-label study. After a 3-week baseline, patients received a subcutaneous loading dose of rilonacept 320 mg followed by weekly subcutaneous doses of 160 mg for up to 1 year. Efficacy was determined by patient-based daily health assessment forms, physician's global assessment (PGA), and measurement of inflammatory markers including C-reactive protein (CRP), serum amyloid A (SAA), and S100 calcium-binding protein A12 (S100A12).

RESULTS

Treatment with rilonacept resulted in a rapid clinical response as demonstrated by significant reductions in daily health assessment scores and PGA scores compared with baseline levels (P < 0.05). These effects, which were accompanied by reductions in CRP and SAA, continued over the treatment duration. Rilonacept treatment was well tolerated. There were no treatment-related severe adverse events and no clinically significant changes in laboratory safety parameters.

CONCLUSION

Rilonacept was effective and well tolerated in patients with SchS and may represent a promising potential therapeutic option.

The dermatology view of hereditary angio-oedema: practical diagnostic and management considerations

Hereditary angio-oedema (HAE) is characterized by recurrent, localized, non-pitting, non-pruritic, non-urticarial oedema. Nearly all patients experience skin swelling as a feature of HAE. There may be painful abdominal attacks, accompanied by nausea and vomiting. The disease is life-threatening should laryngeal oedema occur. HAE results from a deficiency or dysfunction of C1 inhibitor, a plasma protein with an important role in regulating the contact, complement and fibrinolytic systems. Effective management of HAE should include a plan for treatment of attacks, as well as routine and preprocedure prevention. Acute and prophylactic therapy with C1 inhibitor therapy for correcting the underlying deficiency in HAE is a valuable option.

An internet survey on self-reported food allergy in Greece: clinical aspects and lack of appropriate medical consultation

BACKGROUND

Food allergy (FA) represents a common and worldwide disorder but in publications referring to FA the reported diagnosis is rarely confirmed. Consequently, the subjectively assessed FA may negatively affect the quality of life of patients and their families.

OBJECTIVE

We have conducted this internet survey in order to estimate the self-reported perception of FA in Greece.

METHODS

A standard anonymous questionnaire was posted for a 3-month period on http://www.in.gr, a Greek popular Internet portal. Each individual could participate only once. Participants were screened for the presence or history of FA by a key question and were then asked to provide information on symptoms, course and management.

RESULTS

A total of 3673 adult subjects (mean age 34.2 years, range 18-74, females 61.3%), reporting FA were included in analysis. Most reported reactions were related to fruits (14.9%), seafood (10.7%) and nuts (9.2%). The first episode occurred principally during the second (29.2%) and third (30.9%) decade within 3 h from consumption (82.2%). Predominant symptoms were urticaria and oral allergy syndrome (almost 25% each one). Nearly half of the participants sought no medical advice, while 31.4% asked for an allergist's consultation. Almost 21% of reactors were hospitalized; nuts, severity of symptoms (lower respiratory and/or cardiovascular), onset in lower age, previous exercise and concomitant alcohol and/or aspirin intake were positively associated with hospitalization.

CONCLUSION

Although FA causes severe anaphylactic episodes, almost 50% of individuals who experience symptoms perceived as FA do not seek medical advice. Awareness programmes must be carried out in order to increase consciousness about this potentially fatal medical condition.