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

Effect of Lactobacillus paracasei ST11 on a nasal provocation test with grass pollen in allergic rhinitis

BACKGROUND

Probiotics have been associated with prevention and improvement of symptoms in atopic diseases such as atopic dermatitis. However, few studies exist that document their efficacy for upper airways allergies such as allergic rhinitis.

OBJECTIVE

To investigate the effect of short-term oral administration of Lactobacillus paracasei ST11 on a nasal provocation test (NPT) with grass pollen.

METHODS

Thirty-one adult volunteers with allergic rhinitis were enrolled in a randomized, double-blind, placebo-controlled study, based on two 4-week cross-over periods of product consumption (ST11-fermented milk vs. placebo), separated by a wash-out period of 6-8 weeks. Objective and subjective clinical parameters of NPT as well as systemic and nasal immunological parameters were compared between the two treatment periods (registration number: NCT 011 50 253).

RESULTS

Subjects that received ST11-fermented milk had lower nasal congestion than subjects under placebo (visual analogical scale; P<0.05). Nasal pruritus followed the same trend. However, no significant change in combined nasal reaction threshold was observed between the two periods. IL-5 secretion by peripheral blood mononuclear cells and serum allergen-specific IgG4 were significantly lower in ST11-fermented milk group compared to placebo group. IL-8 and IL-10 secretion followed the same trend.

CONCLUSION AND CLINICAL RELEVANCE

Short-term treatment with ST11-fermented milk before NPT significantly improved a clinical marker of NPT (subjective nasal congestion) and down-regulated systemic immune markers (IL-5 from peripheral blood mononuclear cells and serum IgG4). These data strongly suggest that probiotics may down modulate key parameters of allergic rhinitis and warrant future evaluation in seasonal trials.

Rhinitis phenotypes correlate with different symptom presentation and risk factor patterns of asthma

BACKGROUND

Asthma and rhinitis frequently coexist, but no population study has previously determined the relationship between nasal comorbidities and symptom expression and risk factors of asthma.

METHODS

In 2008, a postal questionnaire on respiratory health was sent to 30,000 randomly selected subjects aged 16-75 years in West Sweden; 29218 could be traced and 18,087 (62%) responded. The questionnaire included questions on asthma, rhinitis, chronic rhinosinusitis, respiratory symptoms and possible determinants.

RESULTS

Prevalence of allergic rhinitis in asthma was 63.9% and of asthma in allergic rhinitis 19.8%. Prevalence of chronic rhinosinusitis in asthma was 8.4% and of asthma in chronic rhinosinusitis 24.4%. Asthma subjects with chronic rhinitis, or chronic rhinosinusitis, had more symptoms of asthma and bronchitis than those without rhinitis (p < 0.001). There was an obvious trend of higher ORs for various environmental exposures including occupational exposure to dust, gases and fumes (OR 2.32 vs. OR 1.44), visible mould at home (OR 1.72 vs. OR 1.27) and water damage at home (OR 1.82 vs. OR 1.06) for asthma with chronic rhinosinusitis than for asthma with allergic rhinitis. Family history of allergy yielded a higher OR for asthma with allergic rhinitis than with asthma with chronic rhinosinusitis (OR 7.15 vs. OR 4.48).

CONCLUSION

Considerable overlap between asthma and nasal comorbidities was documented, confirming a close relationship between nasal disease and asthma. Allergic rhinitis, chronic rhinitis and chronic rhinosinusitis were associated with different risk factor patterns and symptom expression of asthma. Thus, different nasal comorbidities may reflect different phenotypes of asthma.

Liposomes: a new non-pharmacological therapy concept for seasonal-allergic-rhinoconjunctivitis

Mucosal barrier disorders play an important role in the pathomechanism of the allergic disease. A new approach for their treatment uses liposomes, which consist of phospholipids that make up 75% of the protective nasal surfactant layer. Our aim was to investigate the efficacy of liposomal-based therapy, as a comprehensive treatment alternative to guideline cromoglycate-based therapy, in the treatment of seasonal allergic rhinoconjunctivitis (SAR). We compared nasal and conjunctival symptom reduction with LipoNasal n nasal spray used as monotherapy (LNM), or LipoNasal n nasal spray and Tears Again eye spray combination therapy (LTC), against standard cromoglycate combination therapy (CGC). This prospective, controlled, open observational study was conducted monocentrically. According to their symptoms and preferences 72 patients with SAR were distributed in three equal groups. The study comprised two visits at an interval of 7 days. The efficacy was examined by daily documenting nasal and conjunctival symptom scores. The Nasal-Spray-Sensory-Scale and the Eye-Drops/Spray-Sensory-Scale were used to investigate the tolerability. Quality of life (QoL) was evaluated, using the RHINASTHMA QoL German adapted version. LNM achieved significant improvement in nasal (p < 0.001) and conjunctival symptoms (p = 0.050). The symptom reduction using CGC was equally significant. LTC led to significant nasal symptom relief (p = 0.045). QoL did not improve significantly in all groups (p > 0.05). The tolerability of all treatments was good and no adverse reactions were observed. In all treatment groups the improvement of the nasal and conjunctival symptom scores exceeds the minimal clinically important difference (MCID). The results demonstrate good tolerability and efficacy of non-pharmaceutical liposomal-based treatment (LipoNasal n and Tears Again), given as monotherapy or combination therapy, for nasal and conjunctival symptoms caused by SAR. This study indicates that liposomal-based treatment for SAR may be a comparable alternative to cromoglycate therapy. Further studies are needed to verify these findings.

A national audit of pollen immunotherapy for children in the United Kingdom: patient selection and programme safety

BACKGROUND

Specific immunotherapy (SIT) is an effective treatment for grass and/or tree pollen-induced severe allergic rhinoconjunctivitis. However, there are limited detailed data on the use of immunotherapy in children in the United Kingdom.

OBJECTIVES

We audited NHS paediatric practice against current national guidelines to evaluate patient selection, SIT modalities and adverse events (AEs).

METHODS

Paediatricians offering pollen SIT were identified through the British Society of Allergy and Clinical Immunology Paediatric Allergy Group (BSACI-PAG) and the database of SIT providers compiled for the Royal College of Physicians and Royal College of Pathologists 2010 joint working group. Standardized proformas were returned by 12 of 20 centres (60%), including 12 of 14 centres offering subcutaneous immunotherapy (SCIT) (85%).

RESULTS

Three hundred and twenty-three children, with mean age 11 years at initiation (69% boys), had undergone 528 SIT cycles (SCIT 31%) over 10 years. Fifty-five percent of all patients had asthma. Among SCIT programmes 24.5% patients had perennial (± seasonal) asthma; 75.6% of asthmatics undertaking SCIT had treatments at BTS/SIGN step 2 or above. AEs occurred frequently (50.4% of all SIT cycles) but were mild. In sublingual immunotherapy (SLIT) treatment, local intraoral immediate reactions were most common (44.9% SLIT cycles), as compared with delayed reactions around the injection site in SCIT (28.3% SCIT cycles). An asthma diagnosis had no impact on the number of cycles with AEs, or the severity reported. Few cycles (2.9%) were discontinued as a result of AE(s).

CONCLUSIONS AND CLINICAL RELEVANCE

Pollen SIT is available across England, though small numbers of children are being treated. Current national guidelines to exclude asthmatic children in SIT programmes are not being adhered to by most specialist paediatric allergy centres. SCIT and SLIT has been well tolerated. Review of patient selection criteria is needed and may allow greater use of this therapeutic option in appropriate clinical settings.

Influence of degree of specific allergic sensitivity on severity of rhinitis and asthma in Chinese allergic patients

BACKGROUND

The association between sensitizations and severity of allergic diseases is controversial.

OBJECTIVE

This study was to investigate the association between severity of asthma and rhinitis and degree of specific allergic sensitization in allergic patients in China.

METHOD

A cross-sectional survey was performed in 6304 patients with asthma and/or rhinitis from 4 regions of China. Patients completed a standardized questionnaire documenting their respiratory and allergic symptoms, their impact on sleep, daily activities, school and work. They also underwent skin prick tests with 13 common aeroallergens. Among the recruited subjects, 2268 provided blood samples for serum measurement of specific IgE (sIgE) against 16 common aeroallergens.

RESULTS

Significantly higher percentage of patients with moderate-severe intermittent rhinitis were sensitized to outdoor allergens while percentage of patients sensitized to indoor allergens was increased with increasing severity of asthma. Moderate-severe intermittent rhinitis was associated with the skin wheal size and the level of sIgE to Artemisia vulgaris and Ambrosia artemisifolia (p < 0.001). Moderate-severe asthma was associated with increasing wheal size and sIgE response to Dermatophagoides (D.) pteronyssinus and D. farinae (p < 0.001). Moderate-severe rhinitis and asthma were also associated with increase in number of positive skin prick test and sIgE.

CONCLUSIONS

Artemisia vulgaris and Ambrosia artemisifolia sensitizations are associated with the severity of intermittent rhinitis and D. pteronyssinus and D. farinae sensitizations are associated with increasing severity of asthma in China. Increase in number of allergens the patients are sensitized to may also increase the severity of rhinitis and asthma.

Immunologic effects and tolerability profile of in-season initiation of a standardized-quality grass allergy immunotherapy tablet: a phase III, multicenter, randomized, double-blind, placebo-controlled trial in adults with grass pollen-induced rhinoconjunctivitis

BACKGROUND

The summary of product characteristics of the grass allergy immunotherapy tablet (AIT) (Phleum pratense grass pollen allergen extract) states that clinical effect may be observed in the first pollen season of treatment, if treatment is initiated ≥2 months (8 weeks) before the start of the grass pollen season. However, because patients with grass allergy may first present to physicians during the season, immediate treatment initiation (ie, in-season initiation) may increase treatment compliance and reduce the risk for disease progression compared with asking patients to return before the next pollen season to initiate treatment. This "in-season approach" may offer more patients the potentially beneficial treatment option of specific immunotherapy. However, to date, the immunomodulatory effects and tolerability of in-season treatment initiation is unknown.

OBJECTIVE

The aim of this study was to assess the immunologic effects and tolerability of in-season initiation of treatment with the grass AIT.

METHODS

This multicenter, randomized, double-blind, placebo-controlled trial was carried out in Germany and Austria. Adults with grass pollen allergy (positive skin-prick test and specific grass-pollen immunoglobulin [Ig] E) and grass pollen-induced moderate to severe persistent rhinoconjunctivitis were enrolled. Patients were randomly assigned to receive once-daily grass AIT or placebo, starting during the 2008 grass pollen season and continuing for 8 to 10 weeks. The primary end point was change from baseline in IgE-blocking factor (serum components competing with IgE for allergen binding). Secondary end points included changes from baseline in specific IgE and IgG(4) and measures of tolerability (assessed mainly by adverse events [AEs]). Blood samples for immunologic assessment were obtained by the investigators at baseline and after treatment. All AEs observed by the investigator and/or reported by the patient were recorded throughout the trial and follow-up.

RESULTS

A total of 276 patients were enrolled and formed the full analysis set (mean age, 35 years; 55% men, 45% women; 99% white; mean weight, 76 kg; history of asthma, 41%; mean duration of grass allergy, 15.1 years). No major differences in medical history were found between the grass AIT group (n = 219) and the placebo group (n = 57). The change from baseline in mean concentration of IgE-blocking factor was significantly greater with grass AIT compared with placebo (+0.14 vs +0.05; P < 0.0001). The changes from baseline in specific IgE and specific IgG(4) concentrations were significantly greater with AIT compared with placebo (IgE, +0.59 vs +0.21 log kU/L; IgG(4), +0.18 vs +0.04 log relative units; both, P < 0.0001). At least 1 AE was reported in 58% of patients in the AIT group and in 40% of patients in the placebo group. Most AEs considered related to AIT were mild or moderate events in the mouth, throat, and/or ears (eg, oral pruritus). Four serious AEs were reported in the AIT group (sinusitis, road traffic accident, salmonellosis, meniscus lesion), but all were considered unlikely to be related to treatment. Three percent of the grass AIT group and 2% of the placebo group were withdrawn from the trial due to an AE.

CONCLUSIONS

In-season initiation of grass AIT was associated with an immunomodulatory response in terms of induction of IgE-blocking factor, specific IgE, and specific IgG(4). In-season initiation of grass AIT was generally well tolerated in this group of adults with moderate to severe grass pollen-induced rhinoconjunctivitis. These findings are consistent with those related to the preseasonal initiation of AIT therapy.

Human exposure to allergenic pollens: a comparison between urban and rural areas

BACKGROUND

Pollinosis is found more frequently in urban areas than in rural environments. This could be partly related to the different types of pollen exposure in these dissimilar areas. The objective of this study was to compare the distribution of pollen in these environments across an urbanization gradient.

METHODS

Daily pollen abundances were obtained in France using Hirst-type sensors. Sampling was conducted from January to June in 2003 and 2006 in a rural area, a semi-rural area and in two urban areas, which were characterized by several urbanization criteria.

RESULTS

Total allergenic pollen abundance was higher in rural and semi-rural areas than in urban areas irrespective of the sampling year. Multivariate analyses showed that pollen exposures differed according to the type of area and were strongly explained by the urbanization gradient. Grass, ash, birch, alder, hornbeam, hazel and plantain pollen quantities exceeded the allergy threshold more often in rural settings than in urban areas. In urban areas, only plane pollen quantities exceeded the allergy threshold more often than in rural areas.

CONCLUSIONS

Allergenic pollen exposure is higher in rural areas than in urban areas, and the most abundant pollen in each area did not originated from the same taxa. This result should be taken into account in epidemiological studies comparing allergies in rural and urban areas to adapt the panel of pollen extracts for human environmental exposure. In addition, this study highlights that some ornamental trees produce a large number of allergenic pollens and provide new sources of aeroallergens.

Nares patients have more respiratory infections than allergic subjects

Respiratory infections (RI) represent a frequent challenge for physicians. Allergic patients could present higher susceptibility to contract RI than non-allergic subjects. Non-allergic rhinitis with eosinophils (NARES) has been little investigated. This preliminary study was performed to evaluate the number and duration of RI and their sequelae in NARES and allergic patients, and non-allergic healthy subjects. Forty healthy non-allergic subjects (22 males, mean age 29 years), 40 patients with allergic rhinitis (AR) (19 males, mean age 35), and 40 NARES patients (18 males, mean age 34) were evaluated. The considered parameters were: nasal eosinophils, total number, duration in days of RI, and RI severity. NARES patients had more eosinophils than AR patients and normal controls (p<0.01); RI duration was longer in NARES patients than in AR ones (p<0.05) and controls (p<0.01); RI were more severe in NARES patients than in AR ones (p<0.05) and controls (p<0.01); pneumonia and asthma were more frequent in both NARES and AR patients than controls (p<0.05 and p<0.01). In conclusion, this preliminary study shows that NARES may induce more severe respiratory infections than allergic rhinitis.

Dosing and efficacy in specific immunotherapy

Allergen-specific immunotherapy is used to treat allergic rhinoconjuctivitis and asthma worldwide. The clinical efficacy of the most common routes, subcutaneous (SCIT) and sublingual (SLIT) immunotherapy, is documented for respiratory allergy by double-blind, placebo-controlled, randomised clinical trials (DB PC RCT). However, dose-effect relationships are not available for all extracts. The 1998 WHO Consensus Report on Allergen Immunotherapy found SCIT ineffective at low doses, with high doses more likely to result in an unacceptably high level of systemic reactions. Recent large well-designed DB PC RCTs using SLIT grass pollen tablets have undergone phase II-III studies in adults with allergic rhinitis, yielding proper dose-response studies. These were analysed by the European Academy of Allergy and Clinical Immunology Immunotherapy Interest Group task force on dose effect. In general, low doses (5-7 μg of allergen Phl p 5 per day) are ineffective. Daily doses of 15-25 μg of the major allergen protein are required for significant clinical improvement measured by symptom scores. A higher dose (33-40 μg of Phl p 5 per day) was not more effective than 15-25 μg. Optimization of the allergen/adjuvant ratio may allow for lower allergen doses, increase the safety/efficacy profile and allow for shorter updosing. However, our analysis of the available studies concluded that every product requires its own dose-response relationship study.

Development of a questionnaire to assess experience and preference of intranasal corticosteroids in patients with allergic rhinitis

BACKGROUND

Allergic rhinitis affects 10%-20% of the US population. Its chronic nature, combined with patients' perceptions of safety/efficacy, administration, and sensory attributes of nasal sprays (corticosteroids), impact patient adherence to therapy. The purpose of this study was to develop a measure of experience with and preference for corticosteroid therapy for treatment of allergic rhinitis.

METHODS

Questionnaire development was conducted through qualitative research including concept elicitation and content testing in 153 patients with allergic rhinitis. Patient focus groups (n = 66), in conjunction with content confirmation and saturation in additional groups (n = 87), provided research data. A literature-based conceptual framework was incorporated into the interview guide. An iterative process of data collection, analysis, and theory development yielded the conceptual framework.

RESULTS

Consistent comments from the focus groups combined with those from cognitive debriefing interviews led to the incorporation of 14 finalized attributes into the Experience with Allergic Rhinitis Nasal Spray Questionnaire (EARNS-Q) items. Between the first and second cognitive debriefing interviews, researchers revised the EARNS-Q for retesting. Face and content validity tests indicated that the items, responses, and instructions were understood by study participants. The EARNS-Q is comprised of two modules that measure patient experience with nasal sprays (experience module), and patient preference for a nasal spray relative to another (preference module).

CONCLUSION

The EARNS-Q accurately measured patient experience with and preference for nasal sprays used in treating allergic rhinitis. A potential application of this questionnaire may be as a patient-reported outcomes endpoint in clinical trials of intranasal corticosteroids in patients with allergic rhinitis.

The genetics of asthma and allergic disease: a 21st century perspective

Asthma and allergy are common conditions with complex etiologies involving both genetic and environmental contributions. Recent genome-wide association studies (GWAS) and meta-analyses of GWAS have begun to shed light on both common and distinct pathways that contribute to asthma and allergic diseases. Associations with variation in genes encoding the epithelial cell-derived cytokines, interleukin-33 (IL-33) and thymic stromal lymphopoietin (TSLP), and the IL1RL1 gene encoding the IL-33 receptor, ST2, highlight the central roles for innate immune response pathways that promote the activation and differentiation of T-helper 2 cells in the pathogenesis of both asthma and allergic diseases. In contrast, variation at the 17q21 asthma locus, encoding the ORMDL3 and GSDML genes, is specifically associated with risk for childhood onset asthma. These and other genetic findings are providing a list of well-validated asthma and allergy susceptibility genes that are expanding our understanding of the common and unique biological pathways that are dysregulated in these related conditions. Ongoing studies will continue to broaden our understanding of asthma and allergy and unravel the mechanisms for the development of these complex traits.

Early onset of allergic rhinitis and asthma in recent extra-European immigrants to Milan, Italy: the perspective of a non-governmental organisation

BACKGROUND

Allergy is determined by genetic and environmental factors. People immigrating from under-developed to industrialised countries are at higher risk of developing allergic diseases and immigration is as a good epidemiological model to quantify the influence of the environment. We performed the allergological assessment of 32,555 recent immigrants from different areas of the world to a polluted metropolitan area of Northern Italy.

METHODS

We evaluated time of onset of allergic rhinitis and/or asthma, sensitisations and clinical characteristics of 395 subjects (3.74 ± 2.94 yrs, mean ± SD) from four macro-areas (Asia, Africa, East-Europe, South America) arriving to Milan, Italy from June 2005 to June 2009. Data were compared with immigrants having access to the same medical facility for any medical problem and with resident Italians living in the same area.

RESULTS

Immigrants with allergic rhinitis and/or asthma days since arrival in Italy correlated with number of sensitisations (p=0.0030). Moreover, personal (2.02%) or familial (2.78%) history of allergic diseases was lower in allergic immigrants as compared to allergic residents (37.77 and 29.39%, respectively; p<0.0001 for both comparisons). Finally, the frequency of allergic immigrants from South America (63.3%) was higher than expected from the overall proportion of individuals from this macro-area who sought medical help at the same facility (40.4%; p<0.0001, OR 2.289, CI 2.1670-3.255).

CONCLUSIONS

Environmental factors play a relevant role in the induction of allergies in immigrants to Northern Italy. Genetics appears as a further promoting factor in the case of immigrants from South America.

The rs3761548 polymorphism of FOXP3 is a protective genetic factor against allergic rhinitis in the Hungarian female population

We aimed to study whether forkhead box P3 (FOXP3) polymorphisms contribute to allergic rhinitis (AR) in a Central-European population, the Hungarians, similarly as it was found in Han Chinese. A case-control study was performed and the genotype distribution of the rs3761548 FOXP3 polymorphism was analyzed separately in females and in males. The results demonstrated that females homozygous for the rare FOXP3 rs3761548 allele (A/A) are protected against AR; otherwise, females who are either wild types (C/C) or heterozygote carriers (C/A) of the rare allele are more susceptible to AR (OR [95%CI] = 2.089 [1,095; 3.988]). We were able to confirm the findings of Zhang et al. in a geographically and ethnically distinct population, the Hungarians, and revealed that the rs3761548 SNP is a marker of a haplotype in these two populations, but not in Sub-Saharan Africans, suggesting that this haplotype was fixed after early modern humans left Africa.

Effect of AIT in children including potential to prevent the development of asthma

Allergy specific immunotherapy may alter the natural course of allergic disease. Thus, it is of significant importance, particularly in paediatric populations. Four studies using the grass allergy immunotherapy tablet (AIT) for allergic rhinoconjunctivitis in children showed good clinical outcomes and good safety profiles. Allergic rhinoconjunctivitis often precedes asthma, and treatment with specific immunotherapy has the potential to reduce the development of asthma in children suffering from rhinoconjunctivitis. Since Grazax® AIT has been shown to induce disease modification the prevention of asthma might be hypothesised. The GAP (Grazax® Asthma Prevention) trial is investigating the asthma preventive effect of standardised grass AIT in grass allergic children with rhinoconjunctivitis without asthma. The trial is a 5-year, multicentre, multinational, randomised, double-blind, placebo-controlled, prospective trial for children aged 5-12 years. In a few years, the results will show if grass AIT with Grazax® can prevent the development of asthma in children suffering from allergic rhinoconjunctivitis.

Tissue-type plasminogen activator depletion affects the nasal mucosa matrix reconstruction in allergic rhinitis mice

BACKGROUND

The present study was designed to assess the function of tissue plasminogen activator (t-PA) expression in allergic rhinitis.

METHODS

Age-matched t-PA gene knock out (t-PA(-/-)) and wild type (WT) mice were sensitised four times, and then challenged for six weeks with ovalbumin. The controls were treated with saline instead of ovalbumin. The structural change in the nasal mucosa was investigated with haematoxylin and eosin stain and van Gieson staining. u-PA (urokinase-type plasminogen activator) and PAI-1 (plasminogen activator inhibitor) gene expression were measured by real time PCR. Matrix metalloproteinase-9 (MMP-9) expression was tested with Western blotting and with real time PCR.

RESULTS

After ovalbumin challenge for six weeks, compared with the WT group, t-PA depletion increased collagen deposition and gland hyperplasia. u-PA and PAI-1 gene expression increased both in t-PA(-/-) and in WT mice after ovalbumin treatment. MMP-9 expression decreased greatly after ovalbumin challenge in t-PA(-/-) mice.

CONCLUSION

t-PA affects the nasal mucosa matrix reconstruction process in allergic rhinitis, with which MMP-9 is involved.

Occupational rhinitis in bell pepper greenhouse workers: determinants of leaving work and the effects of subsequent allergen avoidance on health-related quality of life

BACKGROUND

Avoidance of occupational allergens or reduction in exposure has been advocated as the mainstay of the management of occupational rhinitis. Sparse data to the effect of allergen avoidance are available.

OBJECTIVE

To identify factors that may lead to leaving work and to address the effect of subsequent allergen avoidance on quality of life.

METHODS

A survey to the prevalence of occupational allergy to bell pepper performed in 1999 comprised 472 employees, of which 254 had work-related rhinitis and 228 completed the Rhinitis-related Quality of Life Questionnaire. After 8-year follow-up in 2007, 91 workers with rhinitis in 1999 were available to fill out the questionnaire again and were used to evaluate the course of nasal disease in terms of perceived severity and impact on daily life.

RESULTS

Workers with rhinitis at baseline were more likely to leave their job in bell pepper cultivation for another job (OR = 1.62, 95% CI 0.95-2.75). Among the 91 workers, 58 subjects were still at work, whereas 33 subjects had left work. The subjects who left jobs reported substantial improvement in quality of life. The magnitude of the changes ranged from -0.31 to -1. The effect of quitting work on the mean quality of life score amounted -0.76 ± 0.15.

CONCLUSIONS

The current study is the first large longitudinal studies showing that leaving work and subsequent occupational allergen avoidance have a beneficial effect on rhinitis-related quality of life. The study suggests that occupational rhinitis can be a reason to leave work.

Genetic variation in BDNF is associated with allergic asthma and allergic rhinitis in an ethnic Chinese population in Singapore

Allergic diseases affect more than 25% of the world population and result from a complex interplay between genetic and environmental factors. Recent evidence has shown that BDNF (Brain Derived Neurotrophic Factor) could serve as an important marker of allergic disease. Increased levels of BDNF in blood, bronchoalveolar lavage fluid and nasal lavage fluid positively correlate with disease activity and severity in patients with allergic rhinitis (AR), asthma and atopic eczema. However, reports on the association between genetic variation in BDNF and allergic disease have been controversial. This study therefore aims to clarify the relationship between single nucleotide polymorphisms (SNPs) in BDNF and a genetic predisposition to AR and asthma in an ethnic Chinese population of Singapore. Volunteers with a self-reported history of asthma (718 subjects) or a history of AR as determined by a researcher-administered questionnaire (795 subjects) were used in this study, alongside controls with no personal or family history of allergy (717 subjects). The association results identified a significant association for the tagSNP rs10767664 with a significant PDominant=0.0007 and OR=1.3 for AR and PDominant=0.0005 and OR=1.3 for asthma (using a dominant model of association). The haplotype based analysis also identified a significant association further confirming the single SNP association. The SNP rs10767664 is strongly linked (r2=0.95) to the functional polymorphism rs6265 (Val66Met), which has previously been reported to be associated to allergic phenotypes and also shown to affect BDNF expression. BDNF is a therefore a key molecular player in allergy. Further studies on polymorphisms within BDNF may shed light on its role in the pathogenesis of allergic diseases and potentially serve as biomarkers for allergic disease.

Malignancy and specific allergen immunotherapy: the results of a case series

BACKGROUND

Specific immunotherapy with allergen is the only causative treatment for IgE-mediated allergies such as stinging insect allergy or hay fever and works by the induction of blocking antibodies and regulatory T lymphocytes.

OBJECTIVE

Does a hypothetical obstruction of tumor surveillance presupposing the induction of regulatory T cells really justify detaining immunotherapy to oncologic patients as suggested by recent guidelines?

METHODS

We report 6 patients (4 female, 2 male) suffering or having suffered from stage 1 cancer (4 melanomas, 1 lung cancer, 1 breast cancer) and concomitant IgE-mediated allergy. Four of them had a history of severe anaphylactic reactions to the insect yellow jacket, the 5th suffered from allergic rhinoconjunctivitis to dust mites, and the 6th to grass/rye pollen.

RESULTS

Between 2004 and 2010, subcutaneous immunotherapy was safely performed in 5 patients without signs of tumor reactivation. The cancer in 2 of them was diagnosed immediately after specific immunotherapy had been initiated and in another 2 the active cancer phase had already finished years before; the 5th suffered from a relapse around the time of the initiation of immunotherapy. At the time of the writing of the manuscript, 4 of them had already concluded 3 years of treatment, another one almost 1 year. The melanoma in the 6th patient was diagnosed 5 months after reaching the maintenance dose. Immunotherapy with grass/rye pollen was aborted in this patient based on current guidelines.

CONCLUSIONS

Specific immunotherapy was safely administered in patients suffering concomitantly from IgE-mediated allergy and lower stage cancer.

Study of allergic rhinitis in childhood

Allergic rhinitis is common among children and quite often represents a stage of the atopic march. Although sensitization to food and airborne allergens may appear in infancy and early childhood, symptoms of the disease are usually present after age 3. The aim of this study was to determine the most frequent food and indoor and outdoor respiratory allergens involved in allergic rhinitis in children in the region of Piraeus. The study was performed in the outpatient clinic of otolaryngologic allergy of a general hospital. Fifty children (ranged 6–14 ) with symptoms of allergic rhinitis and positive radioallergosorbent test (RAST) for IgE antibodies or skin prick tests were included in the study. Thirty six (72%) of the subjects of the study had intermittent allergic rhinitis. The most common aeroallergens determined were grass pollens and Parietaria, whereas egg and milk were the food allergens identified. The detection of indoor and outdoor allergens in the region of Piraeus, based on skin prick tests and RAST tests, showed high incidence of grasses and food allergens, which is similar to other Mediterranean countries.

Identification of critical amino acids in the IgE epitopes of Ric c 1 and Ric c 3 and the application of glutamic acid as an IgE blocker

BACKGROUND

The allergenicity of Ricinus communis L. (castor bean, Euphorbiaceae) is associated with components of its seeds and pollen. Castor bean allergy has been described not only in laboratory workers, but also in personnel working in oil processing mills, fertilizer retail, the upholstery industry and other industrial fields. In the present study, we describe the critical amino acids in the IgE-binding epitopes in Ric c 1 and Ric c 3, two major allergens of R. communis. In addition, we also investigate the cross-reactivity between castor bean and some air and food allergen extracts commonly used in allergy diagnosis.

METHODOLOGY/PRINCIPAL FINDINGS

The IgE reactivity of human sera from atopic patients was screened by immune-dot blot against castor bean allergens. Allergenic activity was evaluated in vitro using a rat mast cell activation assay and by ELISA. Cross-reactivity was observed between castor bean allergens and extracts from shrimp, fish, gluten, wheat, soybean, peanut, corn, house dust, tobacco and airborne fungal allergens. We observed that treatment of rat and human sera (from atopic patients) with glutamic acid reduced the IgE-epitope interaction.

CONCLUSIONS/SIGNIFICANCE

The identification of glutamic acid residues with critical roles in IgE-binding to Ric c 3 and Ric c 1 support the potential use of free amino acids in allergy treatment.

The role of complement in the diagnosis and management of allergic rhinitis and allergic asthma

Allergic rhinitis and asthma are common chronic inflammatory diseases of the nasal mucus membranes and the upper airways with a high prevalence in Western countries. In addition to maladaptive T-helper type 2 (Th2) immunity, Th17 cells can drive the inflammatory responses in both diseases. Several reports have shown that the complement system is activated locally and systemically in allergic rhinitis and/or allergic asthma patients. Importantly, recent findings in experimental models of allergic rhinitis and allergic asthma suggest that the complement cleavage products complement 3a and complement 5a and the activation of their corresponding receptors in antigen-presenting cells regulate the development of maladaptive Th2 and Th17 immunity. These findings in experimental asthma are corroborated by genome-wide searches and candidate gene studies in humans. We discuss recent findings in experimental and human allergic airway diseases suggesting that complement may serve as a new diagnostic and therapeutic target for both disorders.

Alleviation of allergic rhinitis symptoms with Pyeongwee-San extract (KMP6)

CONTEXT

Allergy is characterized by the overreaction of the immune system. Pyeongwee-San is a traditional Korean medicine which has been used for the treatment of the allergic disorder but the mechanism of action is not clear.

OBJECTIVE

To investigate the effect of Pyeongwee-San extract (KMP6) and its component, hesperidin (HES) in the allergic rhinitis (AR) animal model.

METHOD

We sensitized mice on 1, 5, and 14 days by intraperitoneal injections of 100 μg ovalbumin (OVA) emulsified in 20 mg of aluminum hydroxide and we challenged mice with 1.5 mg OVA. Mice received KMP6 and HES before the intranasal OVA challenge for 10 days.

RESULTS

The number of nose rubs after the OVA challenge in the OVA-sensitized mice was significantly higher than that in the OVA-unsensitized mice. The increased number of nose rub was inhibited by the oral administration of KMP6 or HES. The increased levels of IgE and histamine level in serum of the OVA-sensitized mice were reduced by KMP6 or HES administration. The level of interferon-γ was enhanced while the level of IL-4 was reduced on the spleen tissue of the KMP6 or HES-administered AR mice. Inflammatory proteins level was reduced by KMP6 or HES administration in the nasal mucosa tissue of the OVA-sensitized mice. In the KMP6 or HES-administered mice, mast cells and eosinophils infiltration increased by OVA-sensitization was decreased.

CONCLUSION

These results indicate that KMP6 and HES ameliorate the allergic inflammatory reactions such as AR.

Strategies of mucosal immunotherapy for allergic diseases

Incidences of allergic disease have recently increased worldwide. Allergen-specific immunotherapy (SIT) has long been a controversial treatment for allergic diseases. Although beneficial effects on clinically relevant outcomes have been demonstrated in clinical trials by subcutaneous immunotherapy (SCIT), there remains a risk of severe and sometimes fatal anaphylaxis. Mucosal immunotherapy is one advantageous choice because of its non-injection routes of administration and lower side-effect profile. This study reviews recent progress in mucosal immunotherapy for allergic diseases. Administration routes, antigen quality and quantity, and adjuvants used are major considerations in this field. Also, direct uses of unique probiotics, or specific cytokines, have been discussed. Furthermore, some researchers have reported new therapeutic ideas that combine two or more strategies. The most important strategy for development of mucosal therapies for allergic diseases is the improvement of antigen formulation, which includes continuous searching for efficient adjuvants, collecting more information about dominant T-cell epitopes of allergens, and having the proper combination of each. In clinics, when compared to other mucosal routes, sublingual immunotherapy (SLIT) is a preferred choice for therapeutic administration, although local and systemic side effects have been reported. Additionally, not every allergen has the same beneficial effect. Further studies are needed to determine the benefits of mucosal immunotherapy for different allergic diseases after comparison of the different administration routes in children and adults. Data collected from large, well-designed, double-blind, placebo-controlled, and randomized trials, with post-treatment follow-up, can provide robust substantiation of current evidence.

Specific immunotherapy: beyond the clinical scores

OBJECTIVE

The efficacy of specific immunotherapy always has been evaluated by clinical scores (symptoms or medication intake). Nonetheless, specific immunotherapy possesses some special or "additional" effects, including the carryover effect and the preventive actions, which are unique. Those effects are the consequence of the complex mechanism of action, which induces profound and persistent modifications in the immune response to allergens. The literature is reviewed to evaluate the available experimental data on this.

DATA SOURCES

The main databases (EmBase, Medline, Scopus) were searched.

STUDY SELECTION

Clinical trials of immunotherapy, either randomized or not, including placebo-controlled trials, were selected.

RESULTS

Currently, the carryover effect (persistence of the benefit after stopping the treatment) is well ascertained for injection immunotherapy, whereas fewer data are available for the sublingual route. On the contrary, the demonstration of the prevention of asthma onset relies on 2 randomized studies for sublingual immunotherapy, and 1 single study for subcutaneous immunotherapy.

CONCLUSION

Although additional confirmatory data are needed, possibly obtained with a rigorous methodology, the long-lasting and preventive effects of specific immunotherapy always should be taken into account when the efficacy is evaluated. The additional effects also may have relevant socioeconomic implications.

Diagnostic tools in Rhinology EAACI position paper

This EAACI Task Force document aims at providing the readers with a comprehensive and complete overview of the currently available tools for diagnosis of nasal and sino-nasal disease. We have tried to logically order the different important issues related to history taking, clinical examination and additional investigative tools for evaluation of the severity of sinonasal disease into a consensus document. A panel of European experts in the field of Rhinology has contributed to this consensus document on Diagnostic Tools in Rhinology.

How to design and evaluate randomized controlled trials in immunotherapy for allergic rhinitis: an ARIA-GA(2) LEN statement

Specific immunotherapy (SIT) is one of the treatments for allergic rhinitis. However, for allergists, nonspecialists, regulators, payers, and patients, there remain gaps in understanding the evaluation of randomized controlled trials (RCTs). Although treating the same diseases, RCTs in SIT and pharmacotherapy should be considered separately for several reasons, as developed in this study. These include the severity and persistence of allergic rhinitis in the patients enrolled in the study, the problem of the placebo, allergen exposure (in particular pollen and mite), the analysis and reporting of the study, the level of symptoms of placebo-treated patients, the clinical relevance of the efficacy of SIT, the need for a validated combined symptom-medication score, the differences between children and adults and pharmacoeconomic analyses. This statement reviews issues raised by the interpretation of RCTs in sublingual immunotherapy. It is not possible to directly extrapolate the rules or parameters used in medication RCTs to SIT. It also provides some suggestions for the research that will be needed. Interestingly, some of the research questions can be approached with the available data obtained from large RCTs.

A meta-analysis of Th2 pathway genetic variants and risk for allergic rhinitis

There is a significant genetic contribution to allergic rhinitis (AR). Genetic association studies for AR have been performed, but varying results make it challenging to decipher the overall potential effect of specific variants. The Th2 pathway plays an important role in the immunological development of AR. We performed meta-analyses of genetic association studies of variants in Th2 pathway genes and AR. PubMed and Phenopedia were searched by double extraction for original studies on Th2 pathway-related genetic polymorphisms and their associations with AR. A meta-analysis was conducted on each genetic polymorphism with data meeting our predetermined selection criteria. Analyses were performed using both fixed and random effects models, with stratification by age group, ethnicity, and AR definition where appropriate. Heterogeneity and publication bias were assessed. Six independent studies analyzing three candidate polymorphisms and involving a total of 1596 cases and 2892 controls met our inclusion criteria. Overall, the A allele of IL13 single nucleotide polymorphism (SNP) rs20541 was associated with increased odds of AR (estimated OR=1.2; 95% CI 1.1-1.3, p-value 0.004 in fixed effects model, 95% CI 1.0-1.5, p-value 0.056 in random effects model). The A allele of rs20541 was associated with increased odds of AR in mixed age groups using both fixed effects and random effects modeling. IL13 SNP rs1800925 and IL4R SNP 1801275 did not demonstrate overall associations with AR. We conclude that there is evidence for an overall association between IL13 SNP rs20541 and increased risk of AR, especially in mixed-age populations.

Rhinovirus-associated wheeze during infancy and asthma development

Rhinovirus is commonly associated with bronchiolitis - only second to RSV during the first year life. The prevalence of HRV-bronchiolitis may be very high in predisposed infants. HRV diagnosis is almost exclusively based on PCR, which detects respiratory infections with or without symptoms. Two immunologic factors, interferon responses and atopy, have been associated with susceptibility to HRV-bronchiolitis in multiple studies. The current data supports the hypothesis that susceptibility to HRV-bronchiolitis is likely to be an early manifestation of biased immune responses, which are linked to both decreased viral defence and atopic airway inflammation. Prospective studies have consistently shown that early wheezing associated with HRV infection is closely associated with recurrent wheezing and the development of asthma in children. Collectively, these studies suggest that HRV infection in wheezing children could serve as a clinically useful marker for early identification of asthma prone children. The findings to date provide the rationale for future studies to incorporate rhinovirus illnesses into asthma risk indices.

Validation of ARIA (Allergic Rhinitis and its Impact on Asthma) classification in a pediatric population: the PEDRIAL study

Allergic rhinitis (AR) is the commonest chronic disease in children. Allergic Rhinitis and its Impact on Asthma (ARIA) classification based on symptom duration (intermittent vs. persistent) and severity (mild vs. moderate/severe) has not been yet validated in children. Thus our objective was to validate ARIA classification in children, after determining the severity and duration of AR in a pediatric population, using ARIA definitions. Children aged 6-12 with a diagnosis of AR were included in an observational, cross-sectional, multicenter study. Patients were classified according to ARIA guidelines. AR symptoms were assessed using the Total Four Symptoms Score (T4SS). Severity was also evaluated by the patient using a visual analogue scale (VAS). Comparisons were made by means of a statistical analysis. One thousand two hundred and seventy-five children from 271 centers were included. Among them, 59.5% had intermittent and 40.5% persistent AR, while 60.7% seasonal and 39.3% perennial according to dated classification, with significant differences existing between one classification and another; 89.7% had moderate/severe rhinitis. Significantly higher T4SS and VAS scores were obtained in moderate/severe compared to mild AR. In our experience, the current ARIA classification can be considered a valid tool also in children from 6- to 12-yr old.

IL-22 mRNA in peripheral blood mononuclear cells from allergic rhinitic and asthmatic pediatric patients

T helper (T(H) )-17 lymphocytes are characterized by the expression of many regulatory cytokines, including IL-17A and IL-22, but at present no clinical data are available on the expression of these cytokines in peripheral blood mononuclear cells (PBMC) from allergic asthmatic and rhinitic (AR) children. The aim of this study was to investigate a possible relationship between IL-22 and IL-17A mRNAs and clinical parameters in seroatopic, AR, and asthmatic children. The study, conducted during the pollen season, included 18 healthy and 18 allergic (n=9 asthmatic and n=9 rhinitic) children. Serum total and specific IgE, eosinophil count, and skin prick test were performed; in addition, IL-22 and IL-17A mRNA levels were detected in PBMC from healthy and allergic subjects by quantitative real-time PCR. Despite the absence of the mRNA for the IL-17A cytokine, IL-22 expression was found in PBMC from asthmatic patients, with increased IL-22 mRNA levels in patients with chronic severe respect to those with moderate asthma. A positive correlation between IL-22 mRNA and serum total IgE levels was found in asthmatic children. In addition, higher IL-22 and IL-17A mRNA levels were detected in both AR and asymptomatic seroatopic children, compared to healthy individuals, and a correlation between IL-22 and IL17A mRNA and serum total IgE levels was demonstrated. Moreover, the mRNA level of retinoic acid-related orphan receptor C, the T(H) 17 transcription factor, was found to be increased in AR but not in asthmatic patients. This study provides the first evidence that IL-22 mRNA might be expressed in chronic severe asthmatic and AR children. The expression of IL-22 and IL-17A mRNAs in asymptomatic monosensitized seroatopic children suggests a role of these cytokines in the early events involved in the development of these allergic diseases.

100 years of hyposensitization: history of allergen-specific immunotherapy (ASIT)

Hundred years ago, Leonhard Noon and John Freeman published their pioneering works on allergen-specific immunotherapy (ASIT) using grass pollen extracts. To honor their contribution to the development of ASIT as the only causal treatment of IgE-mediated allergies, we review the history of ASIT that started with the anecdotal descriptions of ASIT performed by the ancient king Mithridates (132-63 B.C.) and Jenner's development of a cowpox vaccine. Following Noon's and Freeman's first controlled human trials, ASIT was performed by a large number of modalities and with a myriad of pharmacologic preparations. These developments range from early aqueous pollen extracts and whole bee extracts to chemically modified allergens (allergoids) and various recombinant allergens. In addition to allergen-specific immunotherapy, non-specific immune response modifiers have been used in the past or are in the developmental stage. Also, currently many innovative experimental approaches of ASIT are studied in animal models and human in vitro systems and will hopefully further broaden the range of allergies that can be treated by ASIT, with enhanced efficacy and further reduced side-effects.

Polysensitization as a challenge for the allergist: the suggestions provided by the Polysensitization Impact on Allergen Immunotherapy studies

INTRODUCTION

Polysensitization, that is, sensitization to more than one allergen family, is a common feature of patients with allergic rhinitis (AR) and significantly impairs their quality of life (QoL). Allergen-specific immunotherapy is the only causal treatment for AR. However, the polysensitization phenomenon may represent a crucial obstacle as far as it concerns the choice of the allergen extract to be used for immunotherapy.

AREAS COVERED

A series of real-life based multi-center studies, named POLISMAIL (Polysensitization Impact on Allergen Immunotherapy), have been designed with the aim of evaluating the behavior of allergists in managing polysensitized AR patients. The effect of immunotherapy treatment in these patients was also evaluated. A single allergen extract was used in two-thirds of patients, whereas a mix of two allergens was chosen in the remaining. The severity grade of AR and the QoL were significantly improved by immunotherapy. Both outcomes confirmed that immunotherapy with one or two allergen extracts achieves a significant improvement in polysensitized patients.

EXPERT OPINION

In conclusion, POLISMAIL studies demonstrate that polysensitization should not represent a counter-indication for prescribing immunotherapy. The choice of limiting sublingual immunotherapy to one to two allergen extracts, preferably separated and at high dosages, is sufficient and effective in improving symptoms and QoL.

Relationship between bronchial hyperreactivity and bronchodilation in patients with allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) may be considered a risk factor for the onset of asthma. Recently, it has been reported that forced expiratory flow between 25% and 75% of vital capacity (FEF(25%-75%)) may predict a positive response to bronchodilation test in asthmatic children. Moreover, bronchial hyperreactivity (BHR) is frequently detected in AR patients.

OBJECTIVE

To evaluate the possible relationship between the response to bronchodilation test and methacholine challenge, also considering the FEF(25%-75%) values in a large group of patients with persistent allergic rhinitis.

METHODS

Three hundred sixty-five consecutive AR patients were evaluated. Clinical examination, spirometry, methacholine bronchial challenge, and bronchodilation test were performed in all patients.

RESULTS

Two hundred forty-one patients (66%) had "positive" results for bronchodilation test; FEF(25%-75%) was abnormal in 78 patients (21.4%), and 76 patients (20.8%) had severe BHR. An FEF(25%-75%) cutoff value of less than 58.5% of predicted may optimally (AUC 0.97) discriminate patients with both severe BHR and reversibility.

CONCLUSION

This study confirms previous studies and increases the strength of the role of FEF(25%-75%) as a marker of early bronchial involvement in patients suffering from persistent allergic rhinitis. Moreover, an FEF(25%-75%) value less than 58.5% of predicted may suggest the co-existence of severe BHR and reversibility.

Systematic reviews of sublingual immunotherapy (SLIT)

Allergic rhinitis is common worldwide, with significant morbidity and impact on quality of life. In patients who don't respond adequately to anti-allergic drugs. Subcutaneous allergen immunotherapy is effective although requires specialist administration. Sublingual immunotherapy may represent an effective and safer alternative. This Cochrane systematic review is an update of one published in 2003. We searched Cochrane ENT Group Trials Register, Central, PubMed, EMBASE, CINAHL, Web of Science, Biosis Previews, Cambridge Scientific Abstarcts, mRCT and additional sources. We included randomised, double-blind, placebo- controlled trials of sublingual immunotherapy in adults and children. Two authors selected studies and assessed them for quality. Data were put into RevMan 5.0 for a statistical analysis. We used standardised mean difference (SMD), with a random effect model to combine data. Sixty studies were included, with 49 suitable for meta-analysis. We found significant reductions in symptoms (SMD -0.49; 95%CI (-0.64 to -0.34, P < 0.00001)) and medication requirements (SMD -0.32; 95%CI (-0.43 to -0.21, P < 0.00001)) compared with placebo. None of the trials reported severe systemic reactions, anaphylaxis or use of Adrenaline. This updated review reinforces the conclusion of the original 2003 Cochrane Review that sublingual immunotherapy is effective for allergic rhinitis and appears a safe route of administration.

Time-series studies on air pollution and daily outpatient visits for allergic rhinitis in Beijing, China

To investigate the effects of urban air quality change on health, we carried out a time-series analysis of daily general practitioner consultations for allergic rhinitis (AR) in Beijing, China. Non-parametric generalized additive model (GAM) was used to analyze the highly non-linear or non-monotonic exposure-response relationship between three air pollutants (namely PM₁₀, SO₂ and NO₂) and daily outpatient visits for AR, after controlling for long term trends, the 'day of the week' effect and confounding meteorological factors. The objective of this study was to assess the possible effects of air pollutants on outpatient visits caused by AR in Beijing during the period 2009-2010. Our work indicates that strong associations exist between daily concentration of the three air pollutants and the daily number of outpatients for AR.

Outcomes and cost comparison of three therapeutic approaches to allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) is a global health problem because of its increasing impact on economics, society, and the individual's quality of life. This study compares the outcomes and cost of three intranasal therapeutic approaches to the treatment of AR.

METHODS

This was a retrospective cohort study using propensity scores to achieve balanced cohorts. The study population included patients ≥16 years of age with at least one intranasal prescription claim, without concurrent nasal polyps or sinusitis. Health care use and costs, airway infections, pharmacy costs, and indicators of unsatisfactory treatment (i.e., treatment augmentation or switching) were evaluated in the 1-year follow-up period using a claims database.

RESULTS

Data from 141,190 patients in intranasal antihistamines (INA) therapy, intranasal steroids (INS) therapy, and intranasal combination therapy (ICT) cohorts were analyzed. The INA cohort showed the lowest rate of change in treatment (switching or augmentation). Switching rates were lowest in the INS therapy cohort, whereas augmentation was lowest in the INA cohort. AR- and asthma-related medication costs were significantly lower in the INA cohort. No differences were observed in airway infections and overall health care costs. Concurrent chronic obstructive pulmonary disorder and asthma were the strongest predictors of health care cost and respiratory infection in the follow-up period.

CONCLUSION

A change in treatment was noted in ∼⅓ of the entire study population. None of the treatments had a remarkable effect on health care costs or the occurrence of airway infections. The INA treatment cohort had lower AR- and asthma-related medication costs.

Identification of B cell epitopes of alcohol dehydrogenase allergen of Curvularia lunata

Background/Objective

Epitope identification assists in developing molecules for clinical applications and is useful in defining molecular features of allergens for understanding structure/function relationship. The present study was aimed to identify the B cell epitopes of alcohol dehydrogenase (ADH) allergen from Curvularia lunata using in-silico methods and immunoassay.

Method

B cell epitopes of ADH were predicted by sequence and structure based methods and protein-protein interaction tools while T cell epitopes by inhibitory concentration and binding score methods. The epitopes were superimposed on a three dimensional model of ADH generated by homology modeling and analyzed for antigenic characteristics. Peptides corresponding to predicted epitopes were synthesized and immunoreactivity assessed by ELISA using individual and pooled patients' sera.

Result

The homology model showed GroES like catalytic domain joined to Rossmann superfamily domain by an alpha helix. Stereochemical quality was confirmed by Procheck which showed 90% residues in most favorable region of Ramachandran plot while Errat gave a quality score of 92.733%. Six B cell (P1–P6) and four T cell (P7–P10) epitopes were predicted by a combination of methods. Peptide P2 (epitope P2) showed E(X)₂GGP(X)₃KKI conserved pattern among allergens of pathogenesis related family. It was predicted as high affinity binder based on electronegativity and low hydrophobicity. The computational methods employed were validated using Bet v 1 and Der p 2 allergens where 67% and 60% of the epitope residues were predicted correctly. Among B cell epitopes, Peptide P2 showed maximum IgE binding with individual and pooled patients' sera (mean OD 0.604±0.059 and 0.506±0.0035, respectively) followed by P1, P4 and P3 epitopes. All T cell epitopes showed lower IgE binding.

Conclusion

Four B cell epitopes of C. lunata ADH were identified. Peptide P2 can serve as a potential candidate for diagnosis of allergic diseases.

Allergic rhinoconjunctivitis doubles the risk for incident asthma--results from a population study in Helsinki, Finland

OBJECTIVE

To examine the incidence of allergic rhinoconjunctivitis and asthma, and to assess allergic rhinoconjunctivitis as a risk factor for incident asthma, we performed a 11-year follow-up postal survey.

METHODS

The original study population was a random population sample of 8000 inhabitants of Helsinki aged 20-69 years in 1996. Participants in the first postal questionnaire survey, 6062 subjects, were invited to this follow-up study, and provided 4302 (78%) answers out of 5484 traced subjects in 2007.

RESULTS

Cumulative incidence of asthma from 1996 to 2007 was 4.0% corresponding to an annual incidence rate of 3.7/1000/year. After exclusion of those with asthma medication or physician-diagnosed chronic bronchitis or COPD at baseline in 1996, the cumulative incidence decreased to 3.5% (incidence rate 3.2/1000/year), and further to 2.7% (2.5/1000/year) when also those reporting recurrent wheeze or shortness of breath during the last year in 1996 were omitted from the population at risk. Remission of asthma occurred in 43 subjects and was 16.9% over 11 years. Cumulative 11-year incidence of allergic rhinoconjunctivitis was 16.9% corresponding to 16.8/1000/year, and cumulative remission was 18.1%. Incidence of allergic rhinoconjunctivitis was significantly lower among those who had lived in the countryside or on a farm during the first 5 years of life, but this was not true for asthma. In multivariate analysis, farm living during the first 5 years of life was protective for the development of allergic rhinoconjunctivitis, OR 0.75 (95%CI 0.57-0.99). Allergic rhinoconjunctivitis was a significant independent risk factor for incident asthma, OR 2.15 (95%CI 1.54-3.02). In the cohort, the prevalence of rhinoconjunctivitis increased from 38.0% in 1996 to 40.9% in 2007, physician-diagnosed asthma from 6.8% to 9.4%, while current smoking decreased from 31.3% to 23.3%.

CONCLUSION

Incidence of allergic rhinoconjunctivitis was higher than in earlier studies, while asthma incidence remained on similar level, both being significantly higher in women. Allergic rhinoconjunctivitis doubled the risk for incident asthma.

The association between fractional exhaled nitric oxide (FeNO) and cat dander in asthmatic children

BACKGROUND

The aim of our study was to assess risk factors of increased FeNO in asthmatic children with no cat at home.

METHODS

It was a retrospective, cross-sectional study. We evaluated data from medical documentation of children with asthma: FeNO results, allergen sensitization, seasonal allergen exposure, FEV(1), allergic rhinitis (AR) diagnosis and cat presence at home. We assessed asthma severity using mean doses of inhaled glucocorticosteroids and a management approach based on control according to the newest guidelines of Global Initiative for Asthma (GINA) throughout the last three months before the measurement of FeNO and spirometry.

RESULTS

316 patients (age 6-18) completed the study. Sensitization to cat dander was associated with the highest median value of FeNO concentration compared to other allergens in our patients (28,4ppb) and co-existing sensitization did not affect FeNO level. Median levels of FeNO increased linearly with patient's age. In asthmatics with AR, the levels of FeNO were increased significantly compared to asthmatics without AR (20.8 vs. 16.3, respectively). We showed that in patients without AR, sensitization to cat allergen was associated with more severe asthma in comparison to other perennial allergy (step 4 vs. other steps according to GINA treatment steps). The above relation was not observed in patients with AR. We did not observe correlation between allergy profile and FEV(1) among patients in neither subgroup nor in general population.

CONCLUSIONS

We revealed that sensitization to cat dander was associated with the highest increase of FeNO concentration compared to other allergens in patients not having any cat at home ever. We also observed that in patients without allergic rhinitis, sensitization to cat allergen, compared to other perennial allergy, was associated with more severe asthma.

Genome-wide association study for atopy and allergic rhinitis in a Singapore Chinese population

Allergic rhinitis (AR) is an atopic disease which affects about 600 million people worldwide and results from a complex interplay between genetic and environmental factors. However genetic association studies on known candidate genes yielded variable results. The aim of this study is to identify the genetic variants that influence predisposition towards allergic rhinitis in an ethnic Chinese population in Singapore using a genome-wide association study (GWAS) approach. A total of 4461 ethnic Chinese volunteers were recruited in Singapore and classified according to their allergic disease status. The GWAS included a discovery stage comparing 515 atopic cases (including 456 AR cases) and 486 non-allergic non-rhinitis (NANR) controls. The top SNPs were then validated in a replication cohort consisting of a separate 2323 atopic cases (including 676 AR cases) and 511 NANR controls. Two SNPs showed consistent association in both discovery and replication phases; MRPL4 SNP rs8111930 on 19q13.2 (OR = 0.69, P(combined) = 4.46×10(-05)) and BCAP SNP rs505010 on chromosome 10q24.1 (OR = 0.64, P(combined) = 1.10×10(-04)). In addition, we also replicated multiple associations within known candidates regions such as HLA-DQ and NPSR1 locus in the discovery phase. Our study suggests that MRPL4 and BCAP, key components of the HIF-1α and PI3K/Akt signaling pathways respectively, are two novel candidate genes for atopy and allergic rhinitis. Further study on these molecules and their signaling pathways would help in understanding of the pathogenesis of allergic rhinitis and identification of targets for new therapeutic intervention.

Respiratory symptoms in firefighters

BACKGROUND

The aim of the present study was to determine the prevalence and risk factors associated with respiratory symptoms in common firefighters in the Netherlands.

METHODS

A total of 1,330 firefighters from the municipal fire brigades of three provinces of the Netherlands were included in the study. All subjects were administered a Dutch web-based version of the European Community Respiratory Health Survey questionnaire.

RESULTS

General respiratory symptoms were associated with the number of fires fought in the last 12 months with odds ratios between 1.2 (95% CI 1.0-1.4) and 1.4 (95% CI 1.2-1.7) per 25 fires. A strong association was found between an inhalation incident and present respiratory symptoms with odds ratios between 1.7 (95% CI 1.1-2.7) and 3.0 (95% CI 1.9-4.7). Adjustments for smoking, sex, atopy, and age did not change any of the associations. After stratification, atopics showed elevated odds ratios.

CONCLUSIONS

It is recommended that firefighters are aware of these elevated healthcare risks associated with exposure to fire smoke and that they increase as much as possible the use of self-contained breathing apparatus.

Impact of mometasone furoate nasal spray on individual ocular symptoms of allergic rhinitis: a meta-analysis

BACKGROUND

Intranasal corticosteroids (INSs) are a mainstay of treatment of allergic rhinitis (AR) nasal symptoms. The INS mometasone furoate nasal spray (MFNS) has well-documented efficacy and safety for the treatment and prophylaxis of nasal symptoms of seasonal AR (SAR) and for the treatment of nasal symptoms of perennial AR (PAR). Increasing interest has focused on whether INSs, including MFNS, may have beneficial effects on the ocular symptoms frequently associated with AR.

METHODS

We performed a meta-analysis of 10 randomized, placebo-controlled trials of the efficacy of MFNS 200 mcg daily in relieving ocular allergy symptoms, including itching/burning, redness, and tearing/watering in both SAR and PAR. Four PAR studies and six SAR studies are included in the analysis. A fixed-effect inverse variance model was used to calculate weighted mean differences, 95% confidence intervals (CIs) for each comparison, and a combined overall treatment effect (Z) with P-value.

RESULTS

In both analyses of SAR and PAR studies, including 3132 patients, all individual ocular symptoms were reduced in patients treated with MFNS. Overall treatment effect was significant for all three individual ocular symptoms in the SAR studies (Z = 9.18 for tearing, Z = 10.15 for itching, and Z = 8.88 for redness; P < 0.00001 for all) and in the PAR studies (Z = 5.94, P < 0.00001 for tearing; Z = 2.43, P = 0.02 for itching; and Z = 2.42, P = 0.02 for redness).

CONCLUSIONS

Our findings add to the growing body of literature supporting the positive class effect of INSs, including MFNS, on ocular symptoms associated with SAR and PAR.

Patient-related factors in rhinitis and asthma: the satisfaction with allergy treatment survey

BACKGROUND

Patient satisfaction with the prescribed treatments represents a crucial issue that may have clinical relevance as it may significantly affect treatment compliance. We designed an observational study to evaluate the satisfaction level concerning different pharmacological treatments for allergic rhinitis (AR) and asthma in a real-life setting.

METHODS

The study was conducted in 21 allergy centres homogeneously distributed in Italy. Three hundred and one patients (46.8% males; 53.2% females; mean [SD] age, 33.1 [13.8] years) with AR and/or asthma were consecutively evaluated. Diagnosis, classification, symptom severity, and satisfaction degree (assessed by a questionnaire) were the parameters considered.

RESULTS

Only 33.5% of the AR patients were satisfied with the rhinitis treatments. Only 40.7% of the asthmatic patients were satisfied with the asthma treatments. Some factors associated with treatment dissatisfaction are as follows: female gender (odds ratio [OR] 2.36; p < 0.01), co-morbidity (OR 2.39; p < 0.05), rhinitis severity (OR 1.39; p < 0.05), asthma severity (OR 2.04; p < 0.05), and antihistamine use (OR 2.53); however, the use of bronchodilators had a favourable impact (OR 0.28; p < 0.05). The relatively low number of subjects prevented performing stratification of patients by treatment classes.

CONCLUSION

The findings of this real-life study strengthen the concept that AR is particularly troublesome and that most allergic patients suffering from both rhinitis and asthma are dissatisfied with prescribed drugs.