Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen)

NOD-like receptors and RIG-I-like receptors in human eosinophils: activation by NOD1 and NOD2 agonists

NOD-like receptors (NLRs) and RIG-I-like receptors (RLRs) are newly discovered pattern-recognition receptors. They detect substructures of bacterial peptidoglycan and viral RNA, respectively, thereby initiating an immune response. However, their role in eosinophil activation remains to be explored. The aim of this study was to characterize the expression of a range of NLRs and RLRs in purified human eosinophils and assess their functional importance. Expression of NOD1, NOD2, NLRP3, RIG-I and MDA-5 was investigated using real-time reverse transcription PCR, flow cytometry and immunohistochemistry. The effects of the corresponding agonists iE-DAP (NOD1), MDP (NOD2), alum (NLRP3) and poly(I:C)/LyoVec (RIG-I/MDA-5) were studied in terms of cytokine secretion, degranulation, survival, expression of adhesion molecules and activation markers, and chemotactic migration. Eosinophils expressed NOD1 and NOD2 mRNA and protein. Low levels of RIG-I and MDA-5 were found, whereas expression of NLRP3 was completely absent. In accordance, stimulation with iE-DAP and MDP was found to induce secretion of interleukin-8, up-regulate expression of CD11b, conversely down-regulate CD62 ligand, increase expression of CD69 and induce migration. The MDP also promoted release of eosinophil-derived neurotoxin, whereas iE-DAP failed to do so. No effects were seen upon stimulation with alum or poly(I:C)/LyoVec. Moreover, the NOD1-induced and NOD2-induced activation was mediated via the nuclear factor-κB signalling pathway and augmented by interleukin-5 and granulocyte-macrophage colony-stimulating factor, but not interferon-γ. Taken together, the NLR system represents a novel pathway for eosinophil activation. The responses are enhanced in the presence of cytokines that regulate T helper type 2 immunity, suggesting that the NLRs constitute a link between respiratory infections and exacerbations of allergic disease.

Nitric oxide metabolites in allergic rhinitis: The effect of pollen allergen exposure

BACKGROUND

Seasonal allergic rhinitis (SAR) is characterised by an inflammation consequent to allergen exposure. Nitric oxide may be involved in allergic inflammation.

OBJECTIVE

This study evaluated the serum nitrite concentrations in SAR patients during and outside pollen exposure in order to estimate activity of nitric oxide synthases.

METHODS

One hundred and two (56 females, 46 males, median age: 28.7 years) were included in this study: 56 with SAR evaluated outside the pollen season and so without allergic inflammation and symptoms, and 46 with SAR evaluated during the pollen season with symptoms. Serum concentrations of nitrite were measured and in those patients exposed to pollens, results were compared to scores of the Visual Analogue Scale for nasal obstruction perception.

RESULTS

Serum nitrite concentrations were higher in SAR patients evaluated outside the pollen season (U=-6.78; p<0.0001), moreover, there was a significant relationship between nasal obstruction perception and nitrite in patients evaluated during the pollen season.

CONCLUSION

This preliminary study demonstrates that serum nitric oxide metabolism depends on allergen exposure.

Maxillary sinus infundibulum narrowing influences sinus abnormalities in spite of the presence or absence of allergy

CONCLUSION

Maxillary sinus abnormalities were demonstrated to be associated with maxillary sinus infundibulum narrowing as well as nasal airflow resistance secondary to nonspecific nasal inflammation.

OBJECTIVES

There is no consensus regarding the pathogenetic roles of allergy and anatomic variations in sinus mucosa abnormalities. We investigated the correlation between allergy and anatomic variations in sinus abnormalities in chronic rhinitis patients in the presence or absence of allergy.

METHODS

In all, 148 adult patients with allergic rhinitis (AR) and non-allergic rhinitis (NAR) were enrolled. Opacification of sinuses, the size of the maxillary sinus infundibulum, Haller cells, and concha bullosa were evaluated based on computed tomography (CT) images. Simultaneously, nasal airflow resistance was measured.

RESULTS

The AR group comprising 105 patients showed maxillary sinus opacification in 45 patients. In the NAR group including 43 patients, soft tissue opacification was observed in 13 patients. There was no significant difference in the incidence of sinus opacification between the AR and NAR groups. Both nasal resistance and the infundibulum size in both the AR and NAR groups with sinus opacification showed significant differences from those without sinus abnormalities. The presence of concha bullosa influenced the sinus opacification in both the AR and NAR groups.

Impairment of lung function might be related to IL-10 and IFN-γ defective production in allergic children

A functional defect of T regulatory cells (Tregs) has been proposed as pathogenic mechanism of allergic reaction. Impairment of lung function frequently occurs in children with respiratory allergy. This study aimed at investigating the possible role of IL-10 and IFN-γ on lung function deterioration in allergic children. Forty children with mild asthma, monosensitized to house dust mites, were evaluated and followed-up for 2 years. Spirometry was performed in all children. IL-10 and IFN-γ were evaluated in in vitro experiments. FEV(1), FVC, and FEF(25-75), evaluated as percent of predicted, significantly diminished over time (p<0.0001, p=0.03, and p<0.0001 respectively). There was a strong relationship between changes in spirometric parameters and IL-10 production and between changes in FEV(1) values and IFN-γ production over time. This preliminary study provided evidence that IL-10 and IFN-γ production could be defective in allergic children prone to develop functional impairment.

Association of subcutaneous allergen-specific immunotherapy with incidence of autoimmune disease, ischemic heart disease, and mortality

BACKGROUND

Subcutaneous allergen-specific immunotherapy (SCIT) is a well-documented treatment of IgE-mediated allergic disease. Little is known about potential effects of SCIT on the risk of other chronic immune-related diseases. Over the years, a few casuistic reports have caused concern that SCIT might act as a trigger of autoimmune disease.

OBJECTIVE

We aimed to investigate the association of SCIT with the incidence of autoimmune disease and ischemic heart disease (IHD), as well as all-cause mortality.

METHODS

All Danish citizens without other known diseases were linked and followed through central registries on medications and hospital admissions. Persons receiving SCIT and persons receiving conventional allergy treatment (CAT; nasal steroids or oral antihistamines) were compared with regard to mortality and development of autoimmune diseases, acute myocardial infarction (AMI), and IHD. Cox regression (survival analysis) with age as the underlying time scale was used to estimate relative risks (hazard ratios [HRs] with 95% CIs) associated with SCIT compared with CAT adjusted for age, sex, vocational status, and income.

RESULTS

During the 10-year study period (1997-2006), a total of 18,841 and 428,484 persons were followed in the SCIT and CAT groups, respectively. Receiving SCIT was associated with lower mortality (HR, 0.71; 95% CI, 0.62-0.81) and lower incidence of AMI (HR, 0.70; 95% CI, 0.52-0.93), IHD (HR, 0.88; 95% CI, 0.73-1.05), and autoimmune disease (HR, 0.86; 95% CI, 0.74-0.99).

CONCLUSION

In this registry-based observational study, receiving SCIT compared with CAT was associated with lower risk of autoimmune disease and AMI, as well as decreased all-cause mortality.

Design and recruitment for the GAP trial, investigating the preventive effect on asthma development of an SQ-standardized grass allergy immunotherapy tablet in children with grass pollen-induced allergic rhinoconjunctivitis

BACKGROUND

Allergic rhinoconjunctivitis is a risk factor for asthma development. Treating the underlying allergy may represent an attractive method of asthma prevention. No regulatory guidance exists in this area, and, to our knowledge, no clinical investigations meeting modern regulatory standards have been published.

OBJECTIVE

The objective of this publication is to describe the rationale behind the design of and report on the recruitment for the ongoing pediatric Grazax Asthma Prevention (GAP) trial.

METHODS

The trial was designed for assessment of the preventive effect of an SQ-standardized grass allergy immunotherapy tablet (AIT) on asthma development, both during treatment and after the end of treatment. (The standardized quality [SQ] procedure is a standardization procedure comprising 3 components: total potency, major allergen content, and assessment of extract complexity.) The trial design was discussed with several European Competent Authorities.

RESULTS

The GAP trial is a multinational, parallel-group, double-blind, placebo-controlled randomized trial. Main eligibility criteria were age of 5 to 12 years, grass pollen-induced allergic rhinoconjunctivitis, no asthma, and no overlapping symptomatic allergies. The children have been randomized 1:1 to receive the grass AIT or placebo once daily for 3 years, followed by a blinded observational period of 2 years. Asthma is assessed by the investigators according to specific diagnostic criteria, used at screening visits before randomization to exclude children with existing asthma, and evaluated at least half-yearly during the trial. Seven months of screening resulted in 812 randomized children at 101 centers in 11 countries.

CONCLUSIONS

To our knowledge, the GAP trial represents the first double-blind, placebo-controlled randomized trial to assess the preventive effect of allergen-specific immunotherapy on asthma development. A total of 812 children were successfully recruited into the trial. EudraCT number: 2009-011235-12.

Sublingual immunotherapy in allergic rhinitis

Current treatment options for allergic rhinitis (AR) include allergen avoidance and environmental control, pharmacotherapy, nasal surgery and immunotherapy. Among these, immunotherapy is the only therapeutic option that modifies fundamental immunologic mechanism by inducing desensitization. Specific allergen immunotherapy has been used for 1 century since 1911 and subcutaneous immunotherapy (SCIT) has been demonstrated to be effective in asthma and AR. However, SCIT has several disadvantages such as inconvenience, invasiveness and potentially severe systemic reactions. Thus, sublingual immunotherapy (SLIT) has recently received much attention around the world as a treatment for AR and is now widely used to replace the subcutaneous route. SLIT has recently been introduced in Korea and is now available for AR treatment in the Asia-Pacific region. This review offers better understanding of SLIT for AR by summarizing published articles and our previous works regarding proposed mechanisms, indication and efficacy, safety and adverse events, and compliance.

Rhinitis in children less than 6 years of age: current knowledge and challenges

Rhinitis is a disease of the upper airway characterized by runny and/or blocked nose and/or sneezing. Though not viewed as a life threatening condition, it is also recognized to impose significant burden to the quality of life of sufferers and their caretakers and imposes an economic cost to society. Through a PubMed online search of the literature from 2006 to September 2011, this paper aims to review the published literature on rhinitis in young children below the age of 6 years. It is apparent from epidemiology studies that rhinitis in this age group is a relatively common problem. The condition has a heterogenous etiology with classification into allergic and non-allergic rhinitis. Respiratory viral infections may play a role in the pathogenesis of long standing rhinitis, but definitive studies are still lacking. Treatment guidelines for management are lacking for this age group, and is a significant unmet need. Although the consensus is that co-morbidities including otitis media with effusion, adenoidal hypertrophy and asthma, are important considerations of management of these children. Pharmacotherapy is limited for young children especially for those below the age of 2 years. This review underscores the lack of understanding of rhinitis in early childhood and therefore the need for further research in this area.

Increasing long-term safety of seasonal grass pollen sublingual immunotherapy: the ECRIT study

OBJECTIVE

The usual build-up phase of days or weeks in allergen-specific immunotherapy entails inconveniences for individuals with symptoms only during the pollen season. Additionally, affected individuals often appear for treatment shortly before the expected start of the season without enough time for titration. This double-blind, placebo-controlled study evaluated the safety of ultra-rush grass pollen immunotherapy with sublingual drops (Staloral)® in co-seasonal treatment over three consecutive seasons.

METHODS

209 patients with grass pollen allergic rhinitis received ultra-rush titration (30, 90, 150 and 300 index of reactivity (IR)) of a five grass pollen mixture or placebo every 20 min at the start of the season, followed by 300 IR daily or placebo until the end of the respective season for three consecutive years. Adverse events were documented.

RESULTS

Mean treatment duration varied between seasons (81.8 - 92.7 days). No systemic or anaphylactic reactions were reported and no unexpected adverse events were observed. Adverse events included application site irritation, oedema, abdominal pain and diarrhoea. Fourteen patients discontinued treatment due to adverse events (placebo: four (6%) patients, verum: ten (7%) patients). Adverse events decreased in frequency over each consecutive year of treatment.

CONCLUSION

Seasonal sublingual immunotherapy with ultra-rush titration is well tolerated even when administered as co-seasonal treatment. It may be a valuable option for patients who present late.

Serum and salivary IgE, IgA, and IgG4 antibodies to Dermatophagoides pteronyssinus and its major allergens, Der p1 and Der p2, in allergic and nonallergic children

Allergic rhinitis (AR) is a public health problem with high prevalence worldwide. We evaluated levels of specific IgE, IgA, and IgG4 antibodies to the Dermatophagoides pteronyssinus (Dpt) house dust mite and to its major allergens (Der p1 and Der p2) in serum and saliva samples from allergic and nonallergic children. A total of 86 children were analyzed, from which 72 had AR and 14 were nonallergic healthy children. Serum IgE and serum/salivary IgG4 levels to Dpt, Der p1, and Der p2 were higher in allergic children whereas serum/salivary IgA levels to all allergens were higher in nonallergic children. IgE levels positively correlated with IgG4 and IgA to all allergens in allergic children, while IgA levels negatively correlated with IgG4 to Dpt and Der p1 in nonallergic children. In conclusion, mite-specific IgA antibodies predominate in the serum and saliva of nonallergic children whereas mite-specific IgE and IgG4 are prevalent in allergic children. The presence of specific IgA appears to have a key role for the healthy immune response to mucosal allergens. Also, specific IgA measurements in serum and/or saliva may be useful for monitoring activation of tolerance-inducing mechanisms during allergen specific immunotherapeutic procedures, especially sublingual immunotherapy.

Genetic predisposition for atopy and allergic rhinitis in the Singapore Chinese population

The prevalence of allergic diseases is high globally, but especially in developed countries, with one in five to one in four individuals affected worldwide. The World Health Organization's "Allergic Rhinitis and its Impact on Asthma 2008 Update" guidelines stated explicitly that over 600 million patients from all countries, all ethnic groups and all ages suffer from allergic rhinitis (AR). There are clear evidences to support the concept that allergic diseases are influenced by genetic predisposition and environmental factors. The genetic basis of AR has been evaluated more intensively in the recent 10-20 years. Advances in technology and statistical methods, such as genome-wide association studies (GWAS) have enabled millions of single nucleotide polymorphisms (SNPs) to be genotyped at rapid pace and for less cost. However these studies have not yet answered the entire heritability profile of the disease. Additionally, environmental influences on these genetic variants cannot be discounted. Hence these allergic diseases must be evaluated as a complex interplay between genetic and environmental factors. This review focuses on the genetic basis of AR, with special emphasis on studies performed in Singapore. Candidate gene based studies and GWAS performed in Singapore cohorts have been discussed to suggest how these diseases could be understood better in a Singapore context which is still applicable to research in AR globally.

The links between chronic rhinosinusitis and asthma

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) and asthma are two leading causes of morbidity with many shared clinical features. Their relationship has initially been linked by the atopic pathway. However, understanding of the true pathophysiology of each of these conditions is still under investigation.

RECENT FINDINGS

Recent studies have described new common pathogens, such as fungi and Staphylococcus aureus, as well as disease biomarkers such as nitric oxide and interleukin (IL)-17A, involved in both asthma and CRS pathophysiology. These new discoveries offer insight into understanding these upper and lower airway diseases and may potentially affect treatment management. In the following review, we intend to provide an overview of the recent developments in the relevant areas of research within the past year.

SUMMARY

Reactions to fungal stimuli and superantigens, as well as biomarkers such as nitric oxide and IL-17A, may play a role in the pathogenesis of asthma and CRS and may explain their historic relationship.

Distinct effects of imperatorin on allergic rhinitis: imperatorin inhibits caspase-1 activity in vivo and in vitro

Because imperatorin (IPT), the furanocoumarins exhibits anti-inflammatory activity, we reasoned that IPT might modulate the allergic rhinitis (AR). The aim of this study was to analyze the regulation of AR by IPT. Here, we show the effect and mechanism of IPT in an ovalbumin (OVA)-induced AR model. The number of rubs after the OVA challenge in the OVA-sensitized mice was significantly higher than that in the OVA-unsensitized mice. The increased number of rubs was inhibited by the oral administration of IPT. The increased levels of IgE and histamine in the OVA-sensitized mice were reduced by IPT administration. The levels of interferon-γ were enhanced, whereas the levels of interleukin (IL)-4 were reduced on the spleen tissue of the IPT-administered AR mice. Protein levels of IL-1β, macrophage inflammatory protein-2, intercellular adhesion molecule-1, and cyclooxygenase-2 were reduced by IPT administration in the nasal mucosa of the OVA-sensitized mice. In the IPT-administered mice, the number of eosinophils and mast cells infiltration increased by OVA-sensitization were also decreased. In addition, IPT inhibited caspase-1 activity in the same nasal mucosa tissue. In activated human mast cells, the receptor-interacting protein 2 (RIP2), IκB kinase (IKK)-β, nuclear factor-κB (NF-κB)/RelA, and caspase-1 activation were increased, but increased RIP2, IKK-β, NF-κB/RelA, and caspase-1 activation were inhibited by the treatment of IPT. In addition, IPT inhibited caspase-1 activity and IL-1β production in IgE-stimulated bone marrow-derived mast cells. We can conclude that IPT exerts significant effects by regulating of caspase-1 activation in AR animal and in vitro models.

Prevalence and impact of rhinitis in asthma. SACRA, a cross-sectional nation-wide study in Japan

BACKGROUND

Asthma and rhinitis are common co-morbidities everywhere in the world but nation-wide studies assessing rhinitis in asthmatics using questionnaires based on guidelines are not available.

OBJECTIVE

To assess the prevalence, classification, and severity of rhinitis using the Allergic Rhinitis and its Impact on Asthma (ARIA) criteria in Japanese patients with diagnosed and treated asthma.

METHODS

The study was performed from March to August 2009. Patients in physicians' waiting rooms, or physicians themselves, filled out questionnaires on rhinitis and asthma based on ARIA and Global Initiative for Asthma (GINA) diagnostic guides. The patients answered questions on the severity of the diseases and a Visual Analog Scale. Their physicians made the diagnosis of rhinitis.

RESULTS

In this study, 1910 physicians enrolled 29,518 asthmatics; 15,051 (51.0%) questionnaires were administered by physician, and 26,680 (90.4%) patients were evaluable. Self- and physician-administered questionnaires gave similar results. Rhinitis was diagnosed in 68.5% of patients with self-administered questionnaires and 66.2% with physician-administered questionnaires. In this study, 994 (7.6%) patients with self-administered and 561 (5.2%) patients with physician-administered questionnaires indicated rhinitis symptoms on the questionnaires without a physician's diagnosis of rhinitis. Most patients with the physician's diagnosis of rhinitis had moderate/severe rhinitis. Asthma control was significantly impaired in patients with a physician's diagnosis of rhinitis for all GINA clinical criteria except exacerbations. There were significantly more patients with uncontrolled asthma as defined by GINA in those with a physician's diagnosis of rhinitis (25.4% and 29.7%) by comparison with those without rhinitis (18.0% and 22.8%).

CONCLUSION

Rhinitis is common in asthma and impairs asthma control.

FEF(25-75) might be a predictive factor for bronchial inflammation and bronchial hyperreactivity in adolescents with allergic rhinitis

Allergic rhinitis and asthma are closely associated. Bronchial hyperreactivity (BHR) is a pathophysiological characteristic of asthma. Allergic inflammation is characterized by eosinophilic infiltrate and may by indirectly assessed by exhaled nitric oxide (FeNO). Forced expiratory flow between 25 percent and 75 percent of vital capacity (FEF25-75) may predict BHR in adult patients with allergic rhinitis. The aim of this study was to evaluate the presence of BHR in a large group of adolescents with allergic rhinitis and whether FEF25-75 might be related with BHR and FeNO. Methods 150 adolescents with allergic rhinitis were enrolled. Clinical examination, skin prick test, spirometry, methacholine challenge, and FeNO were performed in all patients. Results Severe BHR is quite frequent in allergic adolescents. Impaired FEF25-75 values (such as less than 65 percent of predicted) constitute a relevant predictive factor for severe BHR (OR 4.4). FeNO levels were significantly related with BHR. Conclusion This study provides evidence that impaired FEF25-75 values might predict severe BHR and BHR is related with FeNO in adolescents. Therefore, BHR should be suspected in adolescents with low FEF25-75 values.

Nasal endoscopy in children with suspected allergic rhinitis

OBJECTIVES/HYPOTHESIS

Ear, nose, and throat assessment may be frequently requested for children with allergic rhinitis (AR). Nasal endoscopy allows a thorough evaluation of the nose. The aim of the study was to investigate whether there are endoscopic signs predictive for AR diagnosis in a cohort of children with suspected AR.

STUDY DESIGN

Cohort of observational study.

METHODS

There were 176 children (99 males; mean age, 7.5 years) studied. Clinical visit, nasal endoscopy, and skin prick test were performed in all patients. Nasal endoscopic signs were pale turbinates, middle turbinate contact, and inferior turbinate contact. The AR diagnosis was made when nasal symptom history was concordant with sensitization.

RESULTS

AR was diagnosed in 141 children. Inferior and middle turbinate contact were reliable predictive factors for AR (odds ratio 5.38 and 3.42, respectively), whereas pale turbinates did not predict it.

CONCLUSIONS

This study suggests that nasal endoscopy may reveal signs predictive for AR diagnosis in children.

Allergenicity assessment of osmotin, a pathogenesis-related protein, used for transgenic crops

Genetic engineering can enhance abiotic stress tolerance of plants, thereby increasing productivity. The present study investigates allergenicity of osmotin protein used for developing transgenic crops. Bioinformatic analysis of osmotin was performed using SDAP and Farrp allergen databases. Osmotin was cloned in pET22b+ vector, purified to homogeneity, and analyzed for digestibility, heat stability, and IgE binding using atopic patients' sera. Osmotin showed 40-92% and 48-75% homology with allergens in SDAP and Farrp databases, respectively. These cross-reactive allergens were from apple, tomato, peach, capsicum, kiwi fruit, and cypress. Osmotin was resistant to pepsin digestion and heat treatment at 90 °C for 1 h. Osmotin protein showed dose-dependent inhibition with pooled patients' sera. It showed significant IgE binding with 22 of 117 patients' sera who were sensitized to tomato and apple, thus indicating cross-reactivity among tomato, apple, and osmotin allergens. In conclusion, osmotin was identified as a potential allergen and showed cross-reactivity with tomato and apple allergens.

The influence of gender and atopy on the natural history of rhinitis in the first 18 years of life

BACKGROUND

Longitudinal studies of the natural history of childhood and adolescent rhinitis are lacking.

OBJECTIVES

To investigate the natural history of rhinitis up to 18 years of age, and how that is influenced by gender and atopy.

METHODS

The Isle of Wight birth cohort was recruited in 1989 (n=1456). Questionnaire data on nasal symptoms (rhinitis) were collected at 1, 2, 4, 10 and 18 years of age. To define atopy, skin prick tests were conducted at 4, 10 and 18 years. The 12-month period prevalence plus positive and negative transitions (defined as change in disease status in two consecutive study assessments) were stratified by gender and atopic status.

RESULTS

Overall rhinitis prevalence increased from 5.4% at 4 years to 35.8% at 18 years (P<0.001), without gender difference. Atopic rhinitis prevalence increased steadily from 3.4% at 4 years to 27.3% at 18 years (P<0.001), was commoner in boys at 18 years (P=0.02) and associated with greater positive transition in boys from 10 to 18 years (P=0.01). Prevalence of non-atopic rhinitis also increased from 4 to 18 years (P=0.003) and was greater in girls at 18 years (P<0.001) reflecting higher female positive transition from 10 to 18 years (P<0.001). Non-atopic rhinitis negative transition (remission) was highest in early life and reduced in later childhood/adolescence.

CONCLUSION

Atopic rhinitis becomes increasingly common as children grow into adolescents, with stronger associations to male gender. Non-atopic rhinitis shows a female predominance at 18 years as girls 'grow into' it more during adolescence. Our findings suggest differential gender effects on the increasing prevalence of both atopic and non-atopic rhinitis in adolescence.

CLINICAL RELEVANCE

A better understanding of how gender and atopic status influence rhinitis during adolescence emerges from this study. Application of such knowledge could help to improve clinical recognition, judge prognosis and ultimately improve management of this common condition.

Comorbidities in an asthma population 8-29 years old: a study from the Norwegian Prescription Database

PURPOSE

To examine the occurrence of chronic diseases and antimicrobial treatment in an asthma population 8-29 years old, compared with the general population.

METHODS

In this cross-sectional study, the asthma population was identified from the general population (retrieved from a census covering the entire Norwegian population) using filled prescriptions on asthma drugs as a proxy measure of current asthma. The outcome was excess occurrence of specific diseases (comorbidity) among people with asthma, compared with the age-specific general population. Diseases were defined by filled prescriptions with specific diagnostic codes (International Classification of Primary Care 2nd edition [ICPC-2] or International Classification of Diseases 10th revision [ICD-10]) during a 1-year period in the Norwegian Prescription Database. Nine chronic diseases were examined: attention deficit/hyperactivity disorder, epilepsy, migraine, mental illness, cardiovascular disease, diabetes, autoimmune disorders, gastro-oesophageal reflux disease (GORD), and allergy. Additionally, antibacterials recommended for respiratory tract infections and antivirals were examined (defined by Anatomical Therapeutic Chemical codes). Standardized morbidity ratios (SMR) for each disease were calculated.

RESULTS

Fifty-nine percent of the population with asthma had at least one of nine chronic diseases examined, compared with 18% in the general population. Few individuals with asthma had more than one additional chronic disease (6% of male subjects and 8% of female subjects). SMRs were increased for all diseases except diabetes, implying higher than expected occurrence of the specific diseases in people with asthma. This pattern was observed in both age groups (8-19 and 20-29 years) and genders. Allergy and GORD had highest SMR (range 3.2-4.8), whereas the other diseases were in the range 1.2-2.5.

CONCLUSIONS

An excess occurrence of comorbidities was found in the population with asthma. A majority of people with asthma had one additional chronic disease, and few had more than one.

Current control and future risk in asthma management

Despite international and national guidelines, poor asthma control remains an issue. Asthma exacerbations are costly to both the individual, and the healthcare provider. Improvements in our understanding of the therapeutic benefit of asthma therapies suggest that, in general, while long-acting bronchodilator therapy improves asthma symptoms, the anti-inflammatory activity of inhaled corticosteroids reduces acute asthma exacerbations. Studies have explored factors which could be predictive of exacerbations. A history of previous exacerbations, poor asthma control, poor inhaler technique, a history of lower respiratory tract infections, poor adherence to medication, the presence of allergic rhinitis, gastro-oesophageal reflux disease, psychological dysfunction, smoking and obesity have all been implicated as having a predictive role in the future risk of asthma exacerbation. Here we review the current literature and discuss this in the context of primary care management of asthma.

Update of prevalence of self-reported allergic rhinitis and chronic nasal symptoms among adults in Sweden

BACKGROUND

Allergic rhinitis (AR) is the most common immunologic disease, and it renders a considerable burden on both sufferers and society. The prevalence of AR has been increasing worldwide over the past century. The aim of this study was to assess the present prevalence, risk factor patterns and comorbidity of self-reported AR and chronic nasal symptoms in different age groups in Stockholm, Sweden.

METHODS

A postal questionnaire was sent on two occasions, in 2006 to a population aged 30-80 years, randomly selected 10 years previously, and in 2007 to a randomly selected sample of subjects aged 20-69 years. The response rates were 83% and 68%, respectively, and in total, 9792 subjects participated. The questionnaire included questions on self-reported AR, asthma, respiratory and nasal symptoms and possible determinants.

RESULTS

The prevalence of self-reported AR was 28.0% (men 26.6%, women 29.1%, P < 0.01) similar to 10 years previously and 33.6% in ages 30-40 years. Allergic heredity [odds ratio (OR) 4.76, confidence interval (CI) 95% 4.25-5.33], physician-diagnosed asthma (OR 5.29, CI 95% 4.49-6.24) and occupational exposure to dust, gases and fumes (OR 1.49, CI 95% 1.30-1.72) were determinants for AR. Prevalence of chronic nasal congestion was 16.1% and of chronic rhinorrhea 14.1%.

CONCLUSIONS

As a basis for understanding the disease, as well as in planning and prioritizing health-care resources, the study provides information about the current prevalence and determinants of self-reported AR and chronic nasal symptoms. Further, comparing with previous studies, the present study suggests that a plateau in the prevalence of AR may have been reached in Sweden.

Atopic dermatitis and the atopic march: what is new?

Objective. In this paper the authors review the management of atopic dermatitis (AD) and the association between AD and allergic respiratory diseases. Data Sources. PubMed databases, researching articles in the last 15 years. Results. Studies about atopic march are cross-sectional population studies at different ages. They show that the most important predisposing factor for atopy is a decrease of the filaggrin's expression. Conclusions. The most modern theories seem to show that the most important factor which starts the atopic march is represented by an impaired epidermal barrier. It causes an increase in skin permeability to allergens that could induce sensitization even in the airways. The major predisposing factor is a primary inherited epithelial barrier defect resulting from filaggrin gene mutation, but other factors may play a role in this complex mechanism. Further studies are needed to focus on AD treatment and preventive strategies.

One century of allergen-specific immunotherapy for respiratory allergy

Among the treatments available for respiratory allergy, which include allergen avoidance and pharmacotherapy, specific immunotherapy (SIT) is the only treatment able to not only act on the symptoms of allergy but also act on the causes. SIT is the practice of administering gradually increasing doses of the specific causative allergen to reduce the clinical reactivity of allergic subjects and was introduced one century ago. SIT remained an empirical treatment for more than 40 years, but the first controlled trial in 1954 paved the way for the scientific era. At present, SIT may be administered in two forms: subcutaneous (SCIT) and sublingual immunotherapy (SLIT). A large number of trials, globally analyzed in several meta-analyses, evaluated the efficacy and safety of SCIT and SLIT in allergic rhinitis and asthma. Current available data give solid evidence to the clinical efficacy of both SCIT and SLIT in allergic rhinitis and asthma. Providing the recommended doses and administration schedules are adhered to, the safety and tolerability are very good; however, adverse systemic reactions remain a drawback for SCIT. After one century of use, accumulating evidence surrounds SIT and the central role in the management of respiratory allergy.

Sublingual immunotherapy in children with allergic rhinitis: quality of systematic reviews

Systematic reviews have gained popularity as a way to combine the increasing amount of research information. This study assessed the quality of systematic reviews and meta-analyses of sublingual immunotherapy (SLIT) for allergic rhinitis in children, published since 2000. Eligible reviews were identified by searching Medline/Pubmed, Embase, and the Cochrane Library, from 2000 through 2008. Methodological quality was assessed using the assessment of multiple systematic reviews instrument. Ten systematic reviews were included, one of which was published in the Cochrane Library. Eight reviews gave some details about the search strategy. None of the reviews included measures to avoid selection bias. In 60% of the reviews, the methodological quality of the included studies was (partly) assessed. Four reviews pooled the results of individual studies, neglecting clinical heterogeneity. Three of the 10 reviews provided information about sources of funding or grants from industry. Of the 10 reviews, the six reviews with the highest overall score scored 5-8 points, indicating moderate quality. Systematic reviews are useful to evaluate the efficacy of SLIT in children. Although more reviews have become available, the methodological quality could be improved. SLIT for children could be promising, but methodological flaws in the reviews and individual studies are too serious to draw definite conclusions.

Spirometric abnormalities in patients with allergic rhinitis: Indicator of an "asthma march"?

BACKGROUND

Allergic rhinitis (AR) may precede and promote the onset of asthma. However, few studies addressed this issue mainly concerning bronchial physiological parameters. The aim of this study was to assess forced expiratory flow at 25-75% (FEF(25-75)), forced expiratory volume at 1 second (FEV(1)), and response to bronchodilation test in a large group of AR patients.

METHODS

Sixteen hundred five adult AR patients were evaluated. Clinical examination, assessment of nasal obstruction perception by visual analog scale, spirometry, and bronchodilation test were performed in all patients.

RESULTS

There were 8.4% of patients with abnormal FEV(1) values, 24.7% had impaired FEF(25-75), and 66.1% had reversibility with bronchodilation. A trend of spirometric impairment seems to exist in these patients. Age, gender, and duration of rhinitis may be risk factors for these findings. Different grades of bronchial impairment seem to exist.

CONCLUSION

This study highlights the close link between upper and lower airways and suggests the possible existence of a progression from AR toward asthma, such as an "asthma march." Therefore, asthma should be suspected and carefully investigated in AR patients.

The eliciting dose of peanut in double-blind, placebo-controlled food challenges decreases with increasing age and specific IgE level in children and young adults

BACKGROUND

Several risk factors for severe anaphylactic reactions to food in daily life are known. However, to date, it is not possible to predict the severity of allergic reactions to food in the individual patient with accuracy. Some studies show that a history of severe reactions is associated with a lower eliciting dose in double-blind, placebo-controlled food challenges (DBPCFCs). Therefore, in this study, the eliciting dose was used as a measure of clinical sensitivity.

OBJECTIVES

To study whether risk factors for severe allergic reactions to food in daily life such as age, degree of sensitization, and coexistent atopic disease influence the eliciting dose in DBPCFCs in children allergic to peanut.

METHODS

Data from children who had clinical reactions to peanut during DBPCFCs at the University Medical Center Groningen (2001-2009) were analyzed. A Cox regression model was used to analyze the association of the determinants with the eliciting dose.

RESULTS

One hundred twenty-six positive DBPCFCs with peanut were analyzed. Age older than 10 years, a specific IgE level above the lowest tertile (≥ 5.6 kU/L), and the absence of atopic dermatitis were associated with reactions to lower doses: respective hazard ratios 1.89 (95% CI, 1.28-2.81; P = .001), 2.03 (95% CI, 1.37-3.00; P < .0001), and 0.45 (95% CI, 0.29-0.71; P = .001) present versus absent. No significant associations with the eliciting dose were found for sex, the presence of asthma and rhinitis, and the severity of food reactions by history.

CONCLUSIONS

Using the eliciting dose as a measure of clinical sensitivity, greater clinical sensitivity in DBPCFCs to peanut was found to be associated with increasing age, higher specific IgE level, and the absence of atopic dermatitis. This finding may explain why adolescents experience severe allergic reactions in daily life to peanut more often than do younger children.

Maintenance dosing for sublingual immunotherapy by prominent European allergen manufacturers expressed in bioequivalent allergy units

BACKGROUND

Sublingual immunotherapy (SLIT) has become established in Europe, and its efficacy is being evaluated in the United States. The doses used for SLIT in Europe today are difficult to evaluate, because each manufacturer expresses the potency of its extracts differently.

OBJECTIVES

To compare in vitro European SLIT maintenance solutions against US licensed standardized allergenic extract concentrates and to determine the monthly SLIT doses delivered expressed in bioequivalent allergy units ([B]AU).

METHODS

We studied Dermatophagoides pteronyssinus, timothy grass pollen, cat (hair) and short ragweed pollen allergen extracts. The SLIT maintenance solutions of 4 leading European manufacturers and standardized concentrate extracts of 3 US manufacturers were analyzed with the following assays: protein content, relative potency (immunoglobulin E [IgE]-binding enzyme-linked immunosorbent assay [ELISA] inhibition) and major allergen content. The relative monthly allergen dose in (B)AU was calculated for each recommended SLIT schedule.

RESULTS

Relative potency was approximately 10 times higher for US concentrate standardized extracts-which are meant to be diluted-than for European SLIT maintenance solutions of D pteronyssinus and timothy grass pollen. For cat (hair) and short ragweed pollen, the difference was less. Measurements of relative potency and major allergen content correlated well. In our assays, European mite extracts contain a very low quantity of Der p 2 compared with US mites.

CONCLUSION

Recommended SLIT doses in Europe vary widely among the manufacturers, but are consistently lower (Eur1) or higher (Eur4) over all four allergens tested. SLIT efficacy probably depends on additional factors apart from the exact dose. SLIT dose finding studies should be done for each product.

Determinants of patient compliance in allergic rhinoconjunctivitis

PURPOSE OF REVIEW

Noncompliance to the prescribed therapeutic regimen is a worldwide problem, especially for diseases in which symptoms can vary with different patient factors and with seasons. The consequences are poor health outcomes, progression of disease and increased healthcare costs. Reviews conducted across countries and addressing different diseases are consistent in estimating noncompliance between 30 and 50%. To implement strategies and interventions that enhance compliance, a comprehensive analysis of its determinants is essential.

RECENT FINDINGS

Lack of efficacy was reported as the number one reason for discontinuing the intake of medications prescribed for nasal allergies. Studies on glucocorticosteroids, allergen-specific immunotherapy and antihistamines highlighted the importance of patient education, demographic factors, duration of therapy, side-effects and treatment costs, as well as minor details, such as taste and odour, in improving compliance.

SUMMARY

The variation in the methodologies used and the durations of treatments assessed in current compliance research in the field of allergic rhinoconjunctivitis decreases the comparability of results. Therefore, a clear definition of compliance measured in clinical trials with allergic rhinoconjunctivitis sufferers is needed. Moreover, a gold standard for measuring and reporting compliance should be determined to enable better interstudy comparability of the rates and determinants of compliance.

Identification of novel biomarkers in seasonal allergic rhinitis by combining proteomic, multivariate and pathway analysis

Background

Glucocorticoids (GCs) play a key role in the treatment of seasonal allergic rhinitis (SAR). However, some patients show a low response to GC treatment. We hypothesized that proteins that correlated to discrimination between symptomatic high and low responders (HR and LR) to GC treatment might be regulated by GCs and therefore suitable as biomarkers for GC treatment.

Methodology/Principal Findings

We identified 953 nasal fluid proteins in symptomatic HR and LR with a LC MS/MS based-quantitative proteomics analysis and performed multivariate analysis to identify a combination of proteins that best separated symptomatic HR and LR. Pathway analysis showed that those proteins were most enriched in the acute phase response pathway. We prioritized candidate biomarkers for GC treatment based on the multivariate and pathway analysis. Next, we tested if those candidate biomarkers differed before and after GC treatment in nasal fluids from 40 patients with SAR using ELISA. Several proteins including ORM (P<0.0001), APOH (P<0.0001), FGA (P<0.01), CTSD (P<0.05) and SERPINB3 (P<0.05) differed significantly before and after GC treatment. Particularly, ORM (P<0.01), FGA (P<0.05) and APOH (P<0.01) that belonged to the acute phase response pathway decreased significantly in HR but not LR before and after GC treatment.

Conclusions/Significance

We identified several novel biomarkers for GC treatment response in SAR with combined proteomics, multivariate and pathway analysis. The analytical principles may be generally applicable to identify biomarkers in clinical studies of complex diseases.

Characteristics of patients with respiratory allergy in France and factors influencing immunotherapy prescription: a prospective observational study (REALIS)

To describe the sensitization profile of respiratory allergies in France, identifying factors influencing the prescription of allergen immunotherapy (AIT) [Transversal phase (T)], and assess treatment efficacy, tolerability, compliance and satisfaction [Longitudinal phase (L)]. French allergists (600) and pneumo-allergists (600) were offered participation and asked to recruit the first 20 new patients with allergic rhinitis (AR) and/or asthma, consulting for a first time allergy check-up with skin prick-test (T), and 5 patients sensitized to pollens (skin test and/or specific IgE) for whom SLIT with pollens was prescribed (L). In the T phase, 2,714 patients were recruited by 169 specialists, mostly allergists (76.5%). The majority (98%) suffered from AR, alone (57.7%) or with asthma (40.3%) and 80.3% suffered from moderate-to-severe rhinitis, mostly persistent (65.8%). Asthma, when present, was mostly intermittent (63.7%) or mild persistent (20.1%). Sensitization to house dust mites was the most common (64.5%), followed by grass pollens (61.5%), tree pollens (41.6%) and cat danders (30.5%). Poly-sensitization was seen in 73.6% of patients. AIT, mostly sublingual, was recommended in 55.6% of the patients, mostly (78.1%) because of insufficient control with symptomatic treatments. The overall impact of symptoms on QOL, positive skin test to grass pollens, ocular pruritus and/or nasal obstruction and moderate-to-severe rhinitis were significant predictors of SLIT prescription. Poly-sensitization or concomitant asthma were not seen as deterrents. Most patients consulting a specialist for allergy testing suffer from moderate-to-severe rhinitis. Treatment in current practice includes immunotherapy in half of the patients, and follows ARIA recommendations.

Allergic rhinitis in northern vietnam: increased risk of urban living according to a large population survey

BACKGROUND

Little is known about prevalence and risk factors of allergic rhinitis and chronic nasal symptoms among adults in Vietnam. We aimed to estimate the prevalence, risk factor patterns and co-morbidities of allergic rhinitis and chronic nasal symptoms in one urban and one rural area in northern Vietnam.

METHODS

A cross-sectional questionnaire survey was conducted from August 2007 to January 2008 in urban Hoankiem and rural Bavi in Hanoi among adults aged 21-70 years. Of 7008 randomly selected subjects, 91.7% participated in Bavi and 70.3% in Hoankiem.

RESULTS

Allergic rhinitis ever or chronic nasal symptoms were reported by 50.2%. The prevalence of allergic rhinitis ever was considerably higher in Hoankiem compared to Bavi, 29.6% vs 10.0% (p < 0.001). Allergic rhinitis ever and chronic nasal symptoms were both significantly associated with asthma and respiratory symptoms, respectively (p < 0.001). Exposure to gas, dust or fumes at work was significantly associated with allergic rhinitis ever, OR 1.57 (95% CI 1.34 - 1.84), nasal blocking, OR 1.90 (95% CI 1.68 - 2.15) and runny nose, OR 1.32 (95% CI 1.17 - 1.49), while somewhat surprisingly no association with smoking was found. Female sex was a significant risk factor for both nasal blocking and runny nose.

CONCLUSIONS

Allergic rhinitis ever was considerably more common in the urban area. Nasal blocking and runny nose was each reported by about one third of the studied sample with no major urban-rural difference. Further, exposure to air pollution at work was significantly associated with allergic rhinitis ever, nasal blocking and runny nose.

Predictors of hospital admission due to asthma in children and adolescents enrolled in an asthma control program

OBJECTIVE

To determine the clinical characteristics and the predictors of hospital admission due to asthma among children and adolescents with asthma under treatment at a referral center.

METHODS

A retrospective cohort study comprising 151 children and adolescents with asthma, referred from the Unified Health Care System and enrolled in the Asthma and Allergic Rhinitis Control Program in the city of Feira de Santana, Brazil, followed for a period of 12 months and receiving asthma medication at no cost. The chi-square test was used in order to determine the associations between the studied variables and the occurrence of hospital admissions, whereas the Mann-Whitney test was used for the comparison between the groups of hospitalized patients and nonhospitalized patients. The level of significance was set at p < 0.05. Univariate analysis with logistic regression was performed in order to determine the predictors of hospital admission.

RESULTS

Of the 151 patients evaluated, 8 (5.2%) were hospitalized, in a total of 12 hospital admissions. In the univariate analysis, the only variable found to be a predictive factor was greater asthma severity (OR = 13.3; 95% CI: 2.55-70.1).

CONCLUSIONS

The fact that, in our study sample, the principal predictor of hospital admission was greater asthma severity, calls for special attention being given to the care of these patients.

Epidemiological features of allergic rhinitis in four major cities in Western China

Allergic rhinitis (AR), with an increasing uptrend of the prevalence in many developed and developing countries, is a global health problem that affects people of all ages and ethnic groups. However, data on the prevalence of self-reported AR in western China are rare. This study investigated the epidemiological features of self-reported AR in western China. In the cross-sectional, population-based study, a validated questionnaire survey on self-reported AR was carried out in 4 major cities in western China by multistage, stratified and cluster sampling, from January to December 2008. The total prevalence rate was 34.3%, with 32.3% (Chongqing), 34.3% (Chengdu), 37.9% (Urumqi), 30.3% (Nanning), respectively. The prevalence presented to increase with age before 30 years old while decrease with age after 30 years old, and the highest prevalence was in 19-30 years group in Chongqing, Chengdu and Nanning which significantly showed "persistent and moderate-severe" type (P<0.0001); In Urumqi, there wasn't a significant increasing or decreasing trend of prevalence rate with age but with an "intermittent and mild"predominance (P<0.0001). There were no distinct sexual differences in prevalence rates in the 4 cities. The morbidity was positively related to monthly average temperature and sunshine (r=0.76645, P=0.0036; r=0.67303, P=0.0165), but negatively associated with relative humidity (r=-0.64391, P=0.0238) in Urumqi. Interestingly, the monthly morbidity was negatively associate with average temperature, sunshine and precipitation in Nanning (r=-0.81997, P=0.0011; r=-0.60787, P=0.0360; r=-0.59443, P=0.0415). Self-reported AR is becoming common in western China with a rapid development in recent years, affecting about three persons out of ten. The climatic factors may have an indirect impact on the prevalence rate through the effects on the local allergens.

Can early household exposure influence the development of rhinitis symptoms in infancy? Findings from the PARIS birth cohort

BACKGROUND

Allergic rhinitis (AR) has become the most prevalent chronic allergic disorder in childhood, and the role of environment has been questioned, particularly in early life.

OBJECTIVE

To investigate the risk factors for rhinitis symptoms in infants included in the PARIS (Pollution and Asthma Risk: an Infant Study) birth cohort.

METHODS

Infants were invited to participate at age 18 months in a health examination conducted by a pediatrician. Allergic rhinitis was defined as the presence of rhinitis symptoms (runny nose, blocked nose, sneezing in the absence of a cold) combined with biological atopy (elevated total immunoglobulin E [IgE], specific IgE, or eosinophilia) and nonallergic rhinitis (NAR) as symptoms without biological atopy. Information about indoor exposures and lifestyle was collected during a telephone interview when the child was 1 month of age. Risk factors for AR and NAR were studied by using a polytomous regression model.

RESULTS

The prevalence of AR and NAR was 70/1,850 (3.8%) and 99/1,850 (5.4%), respectively. Allergic rhinitis and NAR did not share similar risk factors. Male sex (odds ratio [OR] = 1.99 [1.19-3.32]), parental history of AR (OR = 1.89 [1.16-3.08]), low socioeconomic class (OR = 2.23 [1.05-4.72] for low vs high level), and the presence of cockroaches in the home (OR = 3.15 [1.67-5.96]) were risk factors for AR. Conversely, the presence of particle-board furniture less than 12 months old in the child's bedroom was associated with an increased risk of NAR (OR = 1.87 [1.21-2.90]).

CONCLUSIONS

This study should raise awareness about the impact of indoor exposures, particularly with regard to cockroaches and particle-board furniture, because they could influence the occurrence of noninfectious rhinitis.

Allergen-specific immunotherapy: which outcome measures are useful in monitoring clinical trials?

Various clinical outcome measures are commonly applied in clinical trials on specific immunotherapy for allergic rhinoconjunctivitis with or without asthma to provide evidence of its clinical efficacy. These "primary endpoints" measure clinical symptoms as well as the use for concomitant medication. "Secondary outcome endpoints" are represented by health-related quality of life (HRQoL), "well-days," provocation-tests, in vitro tests and others. This article reviews different methods assessing the clinical outcome of trials on both subcutaneous and sublingual immunotherapy, and highlights potential advantages and drawbacks of each method.

Close collaboration between academia, industry and drug regulators is required in the development of allergen products for specific immunotherapy in children

Modification of the response to allergens at an early stage and thereby of the natural history of a respiratory allergic disease by preventing disease progression would constitute the key benefit of specific immunotherapy (SIT) in children. However, although allergen products for SIT have been on the market on a named-patient basis for many years, long-term efficacy, the optimal duration of the treatment and the optimal dosage have not been sufficiently elaborated until now. The enactment of the Therapy Allergen Ordinance in Germany mandates that allergen products for SIT of the most prevalent allergies must submit an application for marketing authorization to the German authorities. In line with the European Paediatric Regulation, decisions by the European Medicines Agency on agreed paediatric investigation plans must be included in these applications. These regulatory requirements provide a unique opportunity to fill the gap in knowledge concerning the benefits of SIT for children and to obtain the data needed to support evidence-based authorization of allergen products for immunotherapy. This goal can only be achieved through close cooperation between academia, drug regulators and industry as well as parent/patient organizations.

A review of the use of fluticasone furoate since its launch

INTRODUCTION

Fluticasone furoate (FF) is the latest glucocorticoid officially approved for the treatment of allergic rhinitis. FF has shown the highest affinity and selectivity for the glucocorticoid receptors as well the longest tissue retention compared with other available intranasal steroids; these new pharmacologic characteristics provide the basis for its potent and prolonged anti-inflammatory activity at the target site.

AREAS COVERED

A literature review achieved through PubMed and Medline research methods supports the clinical efficacy of FF versus placebo in reducing ocular and nasal symptoms related to allergic rhinitis (at the recommended starting doses of 110 μg once daily for adults and adolescents and 55 μg once daily for children), with a good safety profile. Moreover, the present review also compares FF with other intranasal steroids: FF represents a molecular evolution of fluticasone propionate (FP), and there is scientific evidence of therapeutic advantages over FP.

EXPERT OPINION

Fluticasone furoate is a promising molecule in the treatment of allergic rhinitis as it fits fully all the official guidelines' criteria. It is now being considered as a topical steroid that is quite close to the ideal pharmacological model for glucocorticoids due to its satisfying safety/tolerability profile, both in adults and children, leads FF to be considered as a topical steroid that is quite close to the ideal pharmacologic model for glucocorticoids. More studies should be directed to assess the improvement of quality of life in subjects with allergic rhinitis treated with FF, in comparison with other intranasal steroids and even H1-antihistamines; in addition, it could be also interesting to analyze eventual, additional effects of FF in patients with bronchial asthma, which is frequently associated with allergic rhinitis.

Comparison of nasal cytology and symptom scores in patients with seasonal allergic rhinitis, before and after treatment

OBJECTIVE

To evaluate symptom scores and nasal smear cytology findings in seasonal allergic rhinitis patients, before and after treatment.

METHODS

Twenty-nine consecutive adult patients with seasonal allergic rhinitis were evaluated prospectively. They received mometasone furoate nasal spray and cetirizine for 21 days. Nasal and ocular symptom scores were recorded before and after treatment. Nasal cytology was also assessed as a means of determining treatment.

RESULTS

The combined use of an intranasal corticosteroid and an oral antihistamine caused a significant improvement in nasal and ocular symptom scores. Cytological evaluation revealed significant reduction in nasal eosinophil, neutrophil and goblet cell counts after three weeks' treatment.

CONCLUSION

Symptom scoring systems are widely used for the evaluation of drug efficacy in allergic rhinitis treatment. When investigating the disease and evaluating treatment efficacy, objective as well as subjective methods are needed. Nasal cytological assessment is a simple, objective method which provides valuable information about the nasal mucosa.

Associations of age, gender, and BMI with prevalence of allergic diseases in children: PATCH study

BACKGROUND

Little is known about the prevalence of allergic diseases in children of different ages. This study aimed to investigate the prevalence of allergic diseases and allergic sensitization in children over a wide age range, with emphasis on the influence of age, gender, and body mass index (BMI).

METHODS

In a cross-sectional study, we assessed 5351 Taiwanese children aged 4-18 years using an International Study of Asthma and Allergies in Childhood questionnaire, BMI, and total and specific serum immunoglobulin E.

RESULTS

Forty-eight percent were currently symptomatic for at least one of three allergic diseases. Prevalence of wheeze ever, current wheeze, and diagnosed asthma were 17.0%, 7.5%, and 9.8%, respectively; analogous features for rhinitis were 47.8%, 44.2%, and 39.8%. Allergic sensitization was very common (57.3%). Half of the children (50.6%) with current wheeze had not been diagnosed with asthma by physicians, whereas undiagnosed rates were 32.3% for rhinitis and 25.3% for eczema. The male-to-female prevalence ratios of current wheeze increased with age from <1 at 4-5 years, peaked at 10-11 years (2.24), then reversed to 0.57 at 16-18 years. Childhood wheezing tended to remit with age, but rhinitis and eczema were more persistent. Total immunoglobulin E levels increased with age until 14-15 years, and declined thereafter. Elevated BMI was associated with greater prevalence of wheezing and eczema, with no evidence of significant effect modification by either gender or age. Multivariate analyses revealed that younger age, boys, and obesity were significantly and independently associated with current wheezing in children (all p < .01).

CONCLUSIONS

The burden and co-morbidity of childhood allergies are substantial. There are striking age-dependent gender differences in asthma prevalence, exhibiting an inverted U-shaped curve for male-to-female prevalence ratios by age. Obesity is associated with a greater prevalence of asthma in children with no evidence of a significant modulation by either gender or age.

Nasal allergen provocation test with multiple aeroallergens detects polysensitization in local allergic rhinitis

BACKGROUND

Patients previously given a diagnosis of nonallergic rhinitis (NAR) might have a new form of local allergic rhinitis (LAR) with local production of specific IgE antibodies and a positive response to a nasal allergen provocation test (NAPT).

OBJECTIVE

We evaluated an NAPT protocol using multiple aeroallergens (NAPT-M) for the detection of polysensitization to several aeroallergens in patients with LAR.

METHODS

NAPT-Ms with 2 different panels of aeroallergens for patients with perennial and seasonal rhinitis were performed in 25 patients with LAR and 25 patients with NAR whose disease was diagnosed by means of NAPTs 1 year earlier. The response to nasal challenge was evaluated based on subjective (nasal-ocular symptoms) and objective (acoustic rhinometry) parameters. Nasal levels of tryptase and eosinophil cationic protein were determined by means of immunoassay at baseline, 15 minutes, and 1, 2, and 24 hours after challenge.

RESULTS

NAPT-Ms showed 100% concordance with the gold standard of NAPTs with a single aeroallergen. No false-positive or false-negative responses were detected. The use of NAPT-Ms achieved 75% reduction in the total number of visits required for final diagnosis in the NAR group (from 168 to 42 visits) and a 55% reduction in the LAR group (from 144 to 65 visits) compared with NAPTs with a single aeroallergen.

CONCLUSIONS

These results demonstrate that clinically relevant polysensitization to aeroallergens in patients with LAR occurred and that the NAPT-M is a useful, specific, sensitive, reproducible, and less time-consuming in vivo diagnostic test for the screening of patients with LAR.