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

[Secondary and tertiary prevention of allergic asthma in children]

Asthma is a disease of the lung epithelial barrier, most often associated with allergy in children. Asthma and allergy are two distinct diseases, but the phenotypic expression of asthma depends on atopic status. A better definition of phenotypes of asthma would result in better targeting of prevention and treatment modalities. Secondary prevention aims to prevent the onset of asthma and the acquisition of new sensitizations in sensitized children. Studies concerning allergen avoidance are insufficient to reach a definitive conclusion and antihistamines have not been shown to be effective. The results for specific immunotherapy suggest a benefit to prevent transition from allergic rhinitis to asthma and the onset of new sensitizations. Tertiary prevention aims to reduce symptoms in children with an existing allergic asthma diagnosis. The avoidance of known respiratory allergens will only be effective in combination with management of the whole environment. Specific immunotherapy has a real place, in combination with background therapy. It should be used according to guidelines in appropriately treated patients.

Allergic rhinitis as a predictor for wheezing onset in school-aged children

BACKGROUND

Rhinitis in older children and adults has been shown to be a predictor for adolescent- and adult-onset asthma. These findings suggest an interaction between the upper and lower airways. Whether rhinitis is a predictor for childhood-onset asthma is unknown.

OBJECTIVE

We sought to investigate whether rhinitis in early childhood is an independent predictor for wheezing between the ages of 5 and 13 years in the German Multicentre Allergy Study birth cohort.

METHODS

The German Multicentre Allergy Study cohort initially included 1314 healthy children. They were followed from birth to the age of 13 years with regular questionnaires and interviews. Specific IgE levels were measured at yearly intervals. Airway hyperresponsiveness was assessed at 7 years.

RESULTS

Allergic rhinitis until the age of 5 years was found to be a predictor for developing wheezing between the ages of 5 and 13 years, with an adjusted relative risk of 3.82 (P < .001). This association was not attributable to the type of sensitization, the severity of sensitization, or atopic dermatitis during the first 2 years of life. In this group of children, 41.5% of all new cases of wheezing occurred among children with preceding allergic rhinitis.

CONCLUSIONS

The first manifestation of allergic rhinitis occurs in preschool children in whom it is a predictor for subsequent wheezing onset. Preschool children with rhinitis might thus benefit from early assessment of allergic sensitization to identify the children at high risk of wheezing.

The effect of intranasal corticosteroids on asthma control and quality of life in allergic rhinitis with mild asthma

BACKGROUND

The mechanisms through which rhinitis affects asthma have not been completely elucidated. We explored whether the effect of nasal treatment on asthma control and respiratory-related quality of life (HRQoL) is mediated by inflammatory changes of the upper and lower airways.

METHODS

Allergic rhinitics with mild asthma were randomized to a 14-day treatment period with either nasal budesonide 100 μg, 1 puff per nostril twice a day, or placebo. Clinical, functional, and biological evaluations were performed before and after treatment.

RESULTS

Twenty subjects (M/F: 10/10; age: 31 ± 15 years; mean ± SD) were enrolled, and a total of 17 individuals completely participated in the study. Lung function was within the normal range. The total asthma control test (ACT) score was 20 ± 5.3 and the RHINASTHMA Global Summary (GS) was 44 ± 15. The percentage proportion of eosinophils in nasal lavage was 9.9% and significantly correlated with spirometric parameters reflecting peripheral airway function (for FEF(50): r = 0.48, p = .03; for FEF(25): r = 0.47, p = .03). The pH of the exhaled breath condensate (EBC) was 7.33 ± 0.4. After nasal treatment, the percentage proportion of eosinophils fell significantly (p = .002), and changes in percentage proportion of eosinophils were associated with changes both in the ACT score (r = 0.76, p = .04) and in the RHINASTHMA GS (r = 0.77, p = .02). The increase in the pH of the EBC was not associated with changes in the ACT score or with the RHINASTHMA GS.

CONCLUSIONS

These findings confirm that, in subjects with allergic rhinitis with mild asthma, nasal inflammation impacts on asthma control and HRQoL. The improved control of respiratory symptoms obtained with nasal corticosteroids seems to be mediated by functional changes in the peripheral airways.

[Prevalence and characteristics of rhinitis in adult asthmatic patients attending allergist, primary care and pulmonologist settings in Spain (AIR study)]

BACKGROUND AND OBJECTIVES

Rhinitis and asthma are linked by common epidemiological, clinical and inflammatory features. The objective of the AIR study was to understand the prevalence and characteristics of rhinitis in adult asthmatic patients who were seen in either primary or secondary care (Allergy or Pulmonology) in Spain.

PATIENTS AND METHODS

This was a prospective epidemiological study with the participation of 1,369 randomly selected physicians. Five thousand six hundred sixteen asthmatic patients older than 18 years of age were selected and the study was carried out between February-September 2006. Demographic data, rhinitis prevalence, pulmonary function, allergy tests and treatments were analyzed.

RESULTS

Some 75% (N=4,212) of the asthmatic patients presented with additional rhinitis and these were characterised as being both younger (41.3 vs 50.4 years; p<0.0001) and with less severe asthma (FEV(1)=86.6 vs 79.3%, p<0.0001) than asthmatic patients without rhinitis. A positive correlation was found between asthma and rhinitis severity (p<0.0001) whilst atopy was significantly associated with the presence of rhinitis (81 vs 48%; OR: 4.80; CI 95%: 4.2-5.5). The presence of co-morbid rhinitis was associated with a higher number of asthma exacerbations (p<0.001).

CONCLUSIONS

Some 75% of our asthmatic patients had associated rhinitis and this association was more frequent in atopic subjects. There is a positive correlation between the severity of rhinitis and asthma and between the number of asthma exacerbations and the presence of rhinitis. These results support the main message of ARIA and GEMA recommendations regarding the integral management of airways to improve the control of asthma.

Are chronic urticaria, analgesic intolerance and seasonal rhinitis markers of different severities and phenotypes of the asthma they accompany?

BACKGROUND

Asthma is a heterogeneous disease that presents with different clinical phenotypes. We aimed to compare the patients with asthma diagnosis alone with the patients, who, in addition to their asthma had accompanying analgesic intolerance (AI), chronic urticaria (CU) or seasonal rhinitis (SR) if there are any distinctions and specific characteristics of these defined patient groups.

METHODS

Eighty-four asthma patients diagnosed with SR, 46 with CU, 75 with AI and 71 patients with asthma alone were enrolled to the study retrospectively. The reference group for the comparisons was the group with asthma diagnosis alone.

RESULTS

The mean age of all patients was 37.2±13 (15-80) and 70.7% of them were females. Asthma patients with SR had a significantly earlier onset of asthma (age: 27.4±10.8 and 34.5±15.9; respectively, p<0.01), significantly better pulmonary function tests and were significantly more atopic (92.9% and 28.8%; p<0.001). Moderate-to-severe asthma significantly correlated with older age at the time of diagnosis, older age of asthma onset, higher body mass index, less atopy and fewer pollen sensitivity. Asthma severity of patients with SR was significantly milder than the reference group (OR: 0.6, 95% CI 0.5-0.8). Asthma with AI tended to be more severe although the relation was insignificant (OR:1.6 95% CI:0.8-3.5).

CONCLUSIONS

Asthma patients with SR have significantly milder and earlier onset of asthma, better pulmonary function tests and are significantly more atopic while asthma with AI tends to be more severe. Asthma with CU does not show a specific phenotypic characteristic.

Growing up on a farm leads to lifelong protection against allergic rhinitis

BACKGROUND

Various studies have reported a low prevalence of allergic rhinitis in farmers and farmers' children. We sought to investigate whether the protective effect of childhood farm environment is conserved throughout adulthood and how it corresponds to different degrees of urbanization.

METHODS

A questionnaire on respiratory health was mailed in 2008 to 30,000 randomly selected subjects aged 16-75 in West Sweden, 29,218 could be traced and 18,087 (62%) responded. The questionnaire included questions on allergic rhinitis, asthma, respiratory symptoms and possible determinants.

RESULTS

When stratified into age groups of 15 years, subjects that lived on a farm during their first 5 years of life had a lower prevalence of allergic rhinitis in all groups, even among the oldest (61-75 years). The negative correlation between childhood farm living and prevalence of allergic rhinitis was similar in 46-75 years of age (OR 0.82; 95% CI 0.70-0.95) as in 16-45 years of age (OR 0.78; 0.64-0.95). There was a significant trend of increasing prevalence of allergic rhinitis with increasing degree of urbanization independent of the effect of childhood farm living.

CONCLUSIONS

We found a lifelong protective effect of childhood farm living on the prevalence of allergic rhinitis. In addition, we found an increasing prevalence of allergic rhinitis with increasing degree of urbanization both in those raised on a farm and those not, thus emphasizing the influence of both childhood and adult exposure for the development of allergic disease.

Sublingual immunotherapy may affect serum neopterin: preliminary findings

BACKGROUND

Neopterin is a protein produced by monocytes/macrophages. It has been considered a biomarker of immune activation in several disorders. However, there are few studies in allergic rhinitis (AR). This study evaluated the serum neopterin levels in patients with pollen-induced AR or treated with sublingual immunotherapy (SLIT) and in healthy subjects.

METHODS

146 subjects (70 males, median age 30.5 years): 56 with moderate-severe persistent AR, 40 with AR and successfully treated with 2 year SLIT, and 50 healthy controls were consecutively evaluated outside the pollen season. A skin prick test and blood sampling for assessing serum neopterin levels were performed in all subjects.

RESULTS

SLIT-treated patients had lower neopterin levels than untreated patients and healthy subjects (respectively p=0.012 and p=0.0001).

CONCLUSIONS

Neopterin is a biomarker for immune activation, SLIT may affect serum neopterin probably as a consequence of Treg response to SLIT.

Mometasone Furoate Nasal Spray Provides Early, Continuing Relief of Nasal Congestion and Improves Nasal Patency in Allergic Patients

Background

Patients report nasal congestion as the most bothersome seasonal allergic rhinitis (SAR) symptom. Measurement of this symptom in previous research has largely been based on subjective patient ratings. This study was designed to measure efficacy, onset, and duration of action of the corticosteroid mometasone furoate nasal spray (MFNS) on nasal congestion using an environmental exposure chamber (EEC) and the objective assessment acoustic rhinometry (AcR).

Methods

In a randomized, double-blind, placebo-controlled study, ragweed-sensitive subjects were exposed to ragweed pollen (3500 ± 500 pollen grains/m3) in an EEC (day 1). Subjects rated instantaneous total nasal symptom score (TNSS), including NSS for congestion (NSS-C). Qualifying subjects received MFNS, 200 micrograms, or placebo and rated postdosing symptoms; a subset received MFNS, 200 micrograms, or placebo q.d. for 6 subsequent days, returning to EEC on day 8. Days 1 and 8 assessments included AcR, TNSS, and the Rhinoconjunctivitis Quality of Life Questionnaire developed for use in the EEC (RQOLQ-EEC).

Results

At day 1, hour 6, patients receiving MFNS (n = 155) reported significantly reduced congestion versus placebo (n = 155) per AcR and NSS-C after one dose, showing numerically superior TNSS change from baseline (p = NS). Among the subset who received 6 additional days of treatment, MFNS (n = 78) yielded significantly lower TNSS versus placebo (n = 77) before day 8 EEC entry and throughout 4-hour exposure (p < 0.05), except at 3.5 hours. AcR showed lower congestion with MFNS versus placebo before day 8 EEC exposure and at 24 and 26 hours after final dose (p < 0.05 for all). AcR and NSS-C correlated at multiple time points. Day 8 RQOLQ-EEC between-group scores were significantly different (p = 0.02) for practical problems.

Conclusion

MFNS, 200 micrograms, showed onset of nasal congestion relief at 6 hours and duration of action beyond 24 hours postdosing. Objective and subjective assessments were correlated in subjects with maximal (placebo) or minimal (MFNS treatment) congestion symptoms; both assessments were correlated with improved QOL.

Beneficial effects of chelidonic acid on a model of allergic rhinitis

Chelidonic acid (CA) is known as an inhibitor of the rat brain glutamate decarboxylase. However, the pharmacological effects of CA in allergic reactions have not yet been defined. Here, we show the effects and the mechanism of CA in the ovalbumin (OVA)-sensitized allergic rhinitis (AR) model. CA significantly decreased the number of nasal/ear rubs and increment of IgE levels in the AR mice. The level of interferon-γ was enhanced while the level of IL-4 was reduced on the spleen tissue of the CA-administered AR mice. Expressions of IL-1β and cyclooxygenase-2 were inhibited by CA administration in the nasal mucosa tissues. Infiltration of eosinophils and mast cells was decreased in the CA-administered AR mice. Furthermore, CA decreased the caspase-1 activity in the same nasal mucosa tissue and human mast cell line, HMC-1. Our results indicate that CA may attenuate allergic reaction by inhibition of caspase-1 activity.

Pharmacologic treatment of anaphylaxis: can the evidence base be strengthened?

PURPOSE OF REVIEW

To evaluate the evidence base for the pharmacologic treatment of anaphylaxis.

RECENT FINDINGS

In this review, we focus on four classes of medications (the alpha/beta-agonist epinephrine (adrenaline), H1-antihistamines, H2-antihistamines, and glucocorticoids) that are used in healthcare settings for the initial treatment of anaphylaxis. Epinephrine and many H1-antihistamines and glucocorticoids were introduced before the era of randomized controlled trials and before the era of evidence-based medicine. In anaphylaxis, no randomized controlled trials that are free from methodological problems and meet current standards have been performed with these medications, or with H2-antihistamines. The evidence base for epinephrine injection is stronger than the evidence base for use of other medications in anaphylaxis. Guidelines unanimously recommend prompt injection of epinephrine as the life-saving first-line medication in anaphylaxis; however, they differ in their recommendations for H1-antihistamines, H2-antihistamines, and glucocorticoids. Epinephrine is the only medication that is universally available for anaphylaxis treatment in healthcare settings worldwide. Paradoxically, it is underused in anaphylaxis treatment.

SUMMARY

For ethical reasons, there should never be a placebo-controlled trial of epinephrine in anaphylaxis. We discuss why the possibility of conducting randomized placebo-controlled trials with H1-antihistamines, H2-antihistamines, and particularly with glucocorticoids in anaphylaxis should be considered in order to improve the evidence base for treatment and guide clinical decision-making. We also describe the precautions that will be needed if randomized controlled trials are conducted in anaphylaxis.

Asthma control in adolescents: role of leukotriene inhibitors

Asthma is a chronic inflammatory disease of the airways and is a big burden worldwide. It affects both children and adults, but it is insufficiently studied in adolescents, although this age group has important peculiarities and is challenging to treat, due to, but not exclusively because of, lack of adherence to treatment instructions. Evidence-based guidelines for the treatment of asthma targeting specifically adolescents are lacking, due to the fact that most studies are conducted either on children or in adults. Exercise-induced asthma occurs commonly in adolescents, leading to impaired physical activity. This review describes current treatment options for asthma in adolescents, focusing on leukotriene receptor antagonists, both as a monotherapy and as an add-on therapy for optimal asthma control.

Nod1, Nod2 and Nalp3 receptors, new potential targets in treatment of allergic rhinitis?

BACKGROUND

Recently, a new set of pattern-recognition receptors, the nucleotide-binding oligomerization domain (Nod)-like receptors (NLRs), have emerged. Their activation, either by allergens or microbes, triggers an inflammatory response. The knowledge about NLRs in human airways is limited.

AIM OF THE STUDY

To investigate presence of NLRs in the human nose of healthy individuals and patients with intermittent allergic rhinitis outside and during pollen season.

METHODS

The expression of Nod1, Nod2, and Nalp3 in nasal biopsies was determined with real-time RT-PCR and immunohistochemistry. Cultured primary human nasal epithelial cells (HNECs) were analyzed using real-time RT-PCR and flow cytometry to further verify the presence of NLRs in the epithelium.

RESULTS

Immunohistochemical analysis revealed presence of Nod1, Nod2, and Nalp3 in the nasal epithelium. This was corroborated in cultured HNECs. Patients suffering from symptomatic allergic rhinitis exhibited lower Nod1 and Nalp3 mRNA levels than both controls and patients during pollen season. Nod2 expression was found in all specimens tested, but no differences were seen between the three groups.

CONCLUSION

Nod1, Nod2, and Nalp3 receptors were found to be present in the human nose. The expression of Nod1 and Nalp3 were down-regulated during pollen season among patients with allergic rhinitis. This opens up for new insights and novel therapeutic strategies in inflammatory airway disease.

The impact of concomitant rhinitis on asthma-related quality of life and asthma control

BACKGROUND

Characterizing the interactions between the upper and lower airways is important for the management of asthma. This study aimed at assessing the specific impact of concomitant rhinitis on asthma-related quality of life (QOL) and asthma control.

METHODS

A cross-sectional, observational survey was conducted among 1173 patients with asthma (aged 12-45) recruited by general practitioners and chest physicians. AR was defined by self-reported rhinitis symptoms and previously documented sensitization to inhalant allergens. The primary outcomes were (1) asthma control assessed by the Asthma Control Questionnaire (ACQ) and (2) asthma-specific QOL evaluated through the Mini Asthma Quality of Life Questionnaire (mAQLQ).

RESULTS

AR was present in 73.9% of the population with asthma and nonallergic rhinitis (NAR) in 13.6%. AR and NAR were associated with an increased risk of uncontrolled asthma (i.e. ACQ score > 1.5) with adjusted odds ratios (OR) of 2.00 (95% confidence interval [CI]: 1.35-2.97) and 1.77 (95%CI: 1.09-2.89), respectively. Multivariate linear regression analysis showed that AR and NAR had a modest, although significant, negative impact on the global mAQLQ score (beta coefficient: -0.293, standard error [SE]: 0.063 and beta coefficient: -0.221, SE: 0.080, P < 0.001, respectively), even after adjustment for the level of asthma control and demographic characteristics.

CONCLUSION

This survey provides direct evidence that AR and NAR are associated with an incremental adverse impact on the disease-specific QOL of patients with asthma and the level of asthma control. Further investigations are required to determine whether appropriate treatment of rhinitis would efficiently reduce asthma morbidity.

Comparison of serum specific IgE and skin prick test in polysensitized patients

The aim of this study is to evaluate serum specific-IgE in a large group of polysensitized patients with the same SPT result (such as ++++) comparing two diagnostic methods. Six hundred ten patients (310 females; median age 32 years) suffering from allergic rhinitis were studied. Serum specific-IgE were measured by ImmunoCap assay. Skin prick test was also performed. There was a significant difference between serum specific-IgE values in these polysensitized patients. In conclusion, the serum specific-IgE measurement in polysensitized patients seems to be more appropriate than SPT.

Development and implementation of guidelines in allergic rhinitis – an ARIA-GA2LEN paper

The links between asthma and rhinitis are well characterized. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines stress the importance of these links and provide guidance for their prevention and treatment. Despite effective treatments being available, too few patients receive appropriate medical care for both diseases. Most patients with rhinitis and asthma consult primary care physicians and therefore these physicians are encouraged to understand and use ARIA guidelines. Patients should also be informed about these guidelines to raise their awareness of optimal care and increase control of the two related diseases. To apply these guidelines, clinicians and patients need to understand how and why the recommendations were made. The goal of the ARIA guidelines is to provide recommendations about the best management options for most patients in most situations. These recommendations should be based on the best available evidence. Making recommendations requires the assessment of the quality of available evidence, deciding on the balance between benefits and downsides, consideration of patients’ values and preferences, and, if applicable, resource implications. Guidelines must be updated as new management options become available or important new evidence emerges. Transparent reporting of guidelines facilitates understanding and acceptance, but implementation strategies need to be improved.

Quantification of airborne Aspergillus allergens: redefining the approach

BACKGROUND

Airborne Aspergillus species are significant environmental components involved in the pathogenesis and persistence of allergic respiratory diseases. The detection and quantification of airborne allergens is important to elucidate the clinical implications of environmental exposure of patients suffering with allergic asthma and/or allergic rhinitis.

OBJECTIVE

The authors report a simple volumetric approach to measure atmospheric concentration of four common airborne species of Aspergillus-A. flavus, A. fumigatus, A. niger, and A. tamarii.

METHODS

As particulate aeroallergens may also exist in amorphous form in addition to morphologically identifiable fungal spores/hyphae, a volumetric technique using membrane filters was developed for simultaneous quantification of (a) viable Aspergillus counts, i.e., colony-forming units (cfu)/m(3), and (b) actual Aspergillus allergen content (ng/m(3)) in the air. Further, immunochemically quantified airborne Aspergillus allergens were compared with their corresponding colony counts.

RESULTS

The average monthly aerial counts of the four Aspergillus species recorded during the sampling year were A. flavus: 0.25-15.2 cfu/m(3); A. fumigatus: 1.25-15.6 cfu/m(3); A. niger: 0.75-16.0 cfu/m(3); and A. tamarii: 0.5-11.8 cfu/m(3) of air. Aerial Aspergillus allergen(s) concentration varied from species to species: A. flavus: 26.8-680.8 ng; A. fumigatus: 18.0-380.4 ng; A. niger: 28.2-1879.0 ng; and A. tamarii: 9.2-238.3 ng/m(3) of air. Seasonal distribution of airborne colony counts of the four species didn't correlate with their respective allergen content.

CONCLUSION

Aspergillus allergens were present in the air of Delhi area throughout the year with seasonal variations. The authors feel that by using the immunochemical technique it will be possible to measure actual exposure of patients to various airborne Aspergillus allergens.

Influence of indoor factors in dwellings on the development of childhood asthma

Asthma has become the most common, childhood chronic disease in the industrialized world, and it is also increasing in developing regions. There are huge differences in the prevalence of childhood asthma across countries and continents, and there is no doubt that the prevalence of asthma was strongly increasing during the past decades worldwide. Asthma, as a complex disease, has a broad spectrum of potential determinants ranging from genetics to life style and environmental factors. Environmental factors are likely to be important in explaining the regional differences and the overall increasing trend towards asthma's prevalence. Among the environmental conditions, indoor factors are of particular interest because people spend more than 80% of their time indoors globally. Increasing prices for oil, gas and other sources of primary energy will further lead to better insulation of homes, and ultimately to reduced energy costs. This will decrease air exchange rates and will lower the dilution of indoor air mass with ambient air. Indoor air quality and potential health effects will therefore be an area for future research and for gaining a better understanding of asthma epidemics. This strategic review will summarize the current knowledge of the effects of a broad spectrum of indoor factors on the development of asthma in childhood in Western countries based on epidemiological studies. In conclusion, several epidemiological studies point out, that indoor factors might cause asthma in childhood. Stronger and more consistent findings are seen when exposure to these indoor factors is assessed by surrogates for the source of the actual toxicants. Measurement-based exposure assessments for several indoor factors are less common than using surrogates of the exposure. These studies, however, mainly showed heterogeneous results. The most consistent finding for an induction of asthma in childhood is related to exposure to environmental tobacco smoke, to living in homes close to busy roads, and in damp homes where are visible moulds at home. The causing agents of the increased risk of living in damp homes remained uncertain and needs clarification. Exposure to pet-derived allergens and house dust mites are very commonly investigated and thought to be related to asthma onset. The epidemiological evidence is not sufficient to recommend avoidance measures against pet and dust mites as preventive activities against allergies. More research is also needed to clarify the potential risk for exposure to volatile and semi-volatile organic compounds due to renovation activities, phthalates and chlorine chemicals due to cleaning.

Allergic rhinitis: indicators of quality of life

The objective of this review was to present evidence of the relationship between allergic rhinitis and impairment of quality of life. The data sources were original articles, reviews and consensus statements entered into the Medline and LILACS databases between 1997 and 2008. The following search terms were used: 'allergic rhinitis'; 'quality of life'; and 'sleep disorders'. Quality of life is often impaired in patients with allergic rhinitis, due to the classic symptoms of the disease (sneezing, pruritus, rhinorrhea and nasal obstruction). In addition, the pathophysiology of allergic rhinitis often disrupts sleep, leading to fatigue, irritability, memory deficits, daytime sleepiness and depression. The total burden of this disease goes beyond impairment of physical and social functioning. It has also a financial impact, which becomes greater when we consider the evidence that allergic rhinitis is a possible causal factor of comorbidities, such as asthma and sinusitis. Nasal obstruction, the most prominent symptom, is associated with sleep disorders, which can have a profound effect on mental health, learning, behavior and attention. Finally, allergic rhinitis-a chronic condition that affects adults, adolescents and children-is often underdiagnosed or inadequately treated. The deleterious impact that allergic rhinitis-related sleep disorders have on patient capacity to perform activities of daily living is an important component of the morbidity of the disease. With an accurate diagnosis, there are various available treatments that can reduce the burden of allergic rhinitis.

Impact of rhinitis on asthma control in children: association with FeNO

BACKGROUND

The prevalence of rhinitis is high and frequently observed in association with asthma. Although the persistence of predisposing factors such as rhinitis is frequently observed in adults, this has not yet been confirmed in children.

AIMS

The aim of this present work is to show the relationship between rhinitis and asthma control in asthmatic children.

METHODS

The authors carried out a cross-sectional study by collecting clinical, spirometric, and fractional exhaled nitric oxide (FeNO) data in children aged from 4 to 17 years.

RESULTS

One hundred seventeen children were included. Asthma control was optimal in 37.6%, suboptimal in 55.5% and poor in 7.3% of cases. A 74.3% of children were atopic and 62.5% had symptoms 34 of rhinitis. Rhinitis was more frequent when control of asthma was worse (p = .0001). Age (p = .002), asthma control (p < .001), atopy (p = .001), and presence of rhinitis (p = .012) were significantly associated with FeNO.

CONCLUSIONS

Our study confirms the strong relationship between upper airways and poor asthma control in the asthmatic child. Symptoms of rhinitis may be partly responsible for the increased fractional exhaled nitric oxide (FeNO) level, independently of the control of asthma. Evaluation of rhinitis should be included to improve assessment of asthma control in children.

Endonasal phototherapy significantly alleviates symptoms of allergic rhinitis, but has a limited impact on the nasal mucosal immune cells

The literature documents the fact that UV irradiation of cutaneous Langerhans cells (LC) in vivo prevents the development of contact allergy and produces long-lasting immunosuppression. However, not much is known about the effect of UV irradiation on the LC of the nasal mucosa and their connection with clinical scores. Local antigen presentation may be necessary for both primary and recall T cell responses to birch pollen in patients with hay fever. Endonasal phototherapy combination of UVB (5%), UVA (25%) and visible light (70%) utilises the immunosuppressive effects of UV irradiation. The aim of this study was to correlate clinical symptom scores with possible changes in the LC of the nasal mucosa induced by UV radiation. The clinical effectiveness of this form of treatment is discussed. Nasal biopsies were obtained from ten birch pollen-sensitive patients with seasonal rhinitis before and after endonasal phototherapy. All patients showed a significant clinical benefit post-treatment as assessed by standardised instruments, including total nasal symptom score, nasal congestion score, nasal itching score, sneezing score, nasal secretion score and impairment-to-health score. However, we found no significant morphological changes, to, or quantitative differences in, the CD1a+, CD4, CD8 or CD31 cells before and 14 days after treatment. Despite the positive clinical effect, the study revealed no effect of UV irradiation on the LC and other analysed cells of the nasal mucosa immune system. Possible reasons for this are discussed.

Immunoglobulin Production Pattern in Allergic and Non-Allergic Subjects

Allergic rhinitis (AR) is characterized by Th2 polarized immune response, such as increased IL-4 and reduced IFN-γ production, and by a functional defect of T regulatory cells. This impaired immune response profile influences the pattern of immunoglobulin (Ig) production in allergic patients. However, no studies have compared the pattern of inhalant allergen-specific Ig classes between allergic patients and normal subjects. The aim of this study is to therefore investigate the allergen-specific IgE, IgG, IgG4, and IgA serum level pattern in a group of patients with pollen allergy and in non-allergic healthy subjects. One hundred and two allergic patients (evaluated both out of and in the pollen season) were enrolled. In addition, 50 healthy non-allergic subjects were recruited during the whole year. Serum allergen-specific IgE, IgG, IgG4, and IgA for Parietaria, grasses, and birch were quantitatively determined by the ImmunoCAP System method. Allergen-specific IgE, IgG, IgG4, and IgA serum levels were significantly different for each tested allergen (p=0.0001 for each class) among groups. Allergic patients, mainly during pollen season, showed the highest IgG, IgG4, and IgA levels. The present study therefore provides the preliminary evidence that Ig production pattern toward inhalant allergens may depend on the specificity of the allergenic response both in non-allergic subjects and allergic patients Allergic patients do not show a defect of IgG and IgA classes. In addition, this study is the first that quantitatively evaluates the Ig classes. However, further studies should include non-allergic subjects evaluated both during and out of the pollen season.

Five-grass pollen 300IR SLIT tablets: efficacy and safety in children and adolescents

The efficacy and safety of five-grass pollen 300IR sublingual immunotherapy (SLIT) tablets (Stallergènes SA, France) have previously been demonstrated in paediatric patients. This report presents additional data concerning efficacy at pollen peak, efficacy and safety according to age, nasal and ocular symptoms, use of rescue medication, satisfaction with treatment and compliance. Children (5-11 yr) and adolescents (12-17 yr) with grass pollen-allergic rhinoconjunctivitis were included in a multinational, randomized, double-blind, placebo-controlled study and received either a 300IR five-grass pollen tablet or placebo daily in a pre- (4 months) and co-seasonal protocol. The severity of six symptoms (sneezing, rhinorrhoea, nasal congestion, nasal and ocular pruritis, and tearing) was scored, and rescue medication use was recorded daily during the pollen season. Patient satisfaction was recorded at the season end. A total of 161 children and 117 adolescents were evaluated (n = 267). 300IR SLIT was effective over the whole season (p = 0.0010) and at the pollen peak (p = 0.0009). The adjusted mean difference between 300IR and placebo groups was significant for both nasal (p = 0.0183) and ocular (p < 0.0001) symptoms. Rescue medication use was statistically lower in the SLIT group during the pollen season and at the pollen peak (both p < 0.05). More patients in the SLIT group were satisfied with their treatment compared to placebo (83.2% vs. 68.1%, p = 0.0030), and compliance was high (SLIT 93.9% of patients were compliant, placebo 94.8% of patients were compliant). SLIT was well tolerated by children and adolescents. 300IR five-grass pollen tablets are effective and safe during the pollen season and at the pollen peak in children and adolescents with grass pollen rhinoconjunctivitis.

Inflammatory profiles in nasal mucosa of patients with persistent vs intermittent allergic rhinitis

BACKGROUND

To date there is little information on the inflammatory profiles of patients suffering from persistent (PER) and intermittent allergic rhinitis (IAR). Also, it is not clear whether differences exist in eosinophilic inflammation and/or T-helper cell sub-populations and their markers. The aim of this study was to primarily evaluate the inflammatory profiles of patients with moderate/severe PER and IAR.

METHODS

Inferior nasal turbinate tissue was obtained from 12 PER, 12 IAR and 12 nonallergic nonrhinitic (control) patients, and symptoms (visual analogue scales, VAS) and impairment of life was monitored. All tissues were assessed for eosinophil and mast cell numbers by immunohistochemistry; IL-5, ECP and IgE concentrations by immunoassay; mRNA for transcription factors GATA-3, T-bet, FOXP3 and RORc by quantitative real-time polymerase chain reaction; and IgE-induced release of LTC(4)/D(4)/E(4) and PGD(2)in vitro.

RESULTS

Eosinophils and mast cells were significantly increased in patients with PER and patients with IAR compared to control subjects; by patients with PER demonstrating even significantly greater increase of both cell types than patients with IAR. Similarly, ECP IL-5, GATA-3 mRNA expression and IgE-induced release of LTC4/D(4)/E(4) and PGD(2) from mast cells were significantly increased in patients with PER compared to patients with IAR. In contrast, the expression of T-bet, FOXP3 or RORc mRNA was not significantly different in the PER, IAR or control patients.

CONCLUSION

The findings from the present study suggest that PER is characterized by a significantly greater eosinophilic and predominantly Th2 cell-mediated nasal inflammatory profile compared to IAR.

Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision

BACKGROUND

Allergic rhinitis represents a global health problem affecting 10% to 20% of the population. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines have been widely used to treat the approximately 500 million affected patients globally.

OBJECTIVE

To develop explicit, unambiguous, and transparent clinical recommendations systematically for treatment of allergic rhinitis on the basis of current best evidence.

METHODS

The authors updated ARIA clinical recommendations in collaboration with Global Allergy and Asthma European Network following the approach suggested by the Grading of Recommendations Assessment, Development and Evaluation working group.

RESULTS

This article presents recommendations about the prevention of allergic diseases, the use of oral and topical medications, allergen specific immunotherapy, and complementary treatments in patients with allergic rhinitis as well as patients with both allergic rhinitis and asthma. The guideline panel developed evidence profiles for each recommendation and considered health benefits and harms, burden, patient preferences, and resource use, when appropriate, to formulate recommendations for patients, clinicians, and other health care professionals.

CONCLUSION

These are the most recent and currently the most systematically and transparently developed recommendations about the treatment of allergic rhinitis in adults and children. Patients, clinicians, and policy makers are encouraged to use these recommendations in their daily practice and to support their decisions.

Component-resolved diagnosis for phleum allergy: the role of recombinants

BACKGROUND

Conventional diagnostic tests (such as radioallergosorbent test [RAST] and skin prick test [SPT]) use native raw pollen allergen extracts to establish allergy. However, recombinant allergens may offer important advantages compared with their natural counterparts.

OBJECTIVE

This study evaluated serum immunoglobulin E (IgE) in patients with grass-induced allergic rhinitis (AR) or AR with asthma (ARA), comparing assays with natural or recombinant grass allergens.

METHODS

Sixty patients (33 AR, 27 ARA) positive with SPT and serum IgE for Phleum pratense were enrolled in the study. Serum IgE specific for conventional and recombinant Phleum pratense: rPhl p 1, rPhl p 2, nPhl p 4, rPhl 5b, rPhl p 6, rPhl p 7, rPhl p 11, rPhl p 12, were measured by the IFMA procedure (ImmunoCAP, Phadia, Uppsala, Sweden). Data were expressed as the median (md) and percentiles. Recombinant allergen results were expressed also as the percentage of positive concentrations. The Wilcoxon test was used to compare samples. Because diagnosis is a binary variable (AR/ARA), logistic regression analysis was performed to identify possible correlates.

RESULTS

IgE concentrations assessed with recombinant allergens were significantly higher in ARA patients (p = .05) than in AR patients. A value >5.8 kU/L is the optimal cut-off to discriminate AR and ARA patients. Model specificity was 76%, sensitivity 78%, and efficiency 77%.

CONCLUSION

This study shows that IgEs for natural and recombinant grass pollen allergens are significantly higher in patients with AR and asthma. Moreover, using recombinant allergens it is possible to define a prediction model for diagnosis with 77% efficiency. Therefore, this study may suggest that there are advantages of using recombinant or purified, native allergens over crude extracts.

Efficacy and long-term safety of mometasone furoate nasal spray in children with perennial allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) affects up to 40% of children by age 6 years. Perennial AR (PAR) causes sleep disturbance, diminishes concentration in school, impairs psychosocial functioning, and reduces quality of life. This study evaluated efficacy and long-term safety of the intranasal corticosteroid mometasone furoate nasal spray (MFNS) in children with PAR.

METHODS

This study comprised a double-blind, 4-week efficacy and safety period followed by a 6-month, open-label safety period. Primary efficacy variable during the double-blind period was mean change in physician-evaluated total nasal symptom score (TNSS) from baseline to day 15. Other efficacy variables during this phase included subject-evaluated TNSS, individual nasal symptoms, and total symptom score (TSS, nasal and non-nasal symptoms, summed). Physician-evaluated improvement in overall condition of PAR was assessed during the open-label period. Adverse events (AEs) were monitored throughout.

RESULTS

Subjects aged 3-11 years with PAR (n = 381) were randomized to MFNS 100 microg (n = 190) or placebo (n = 191) daily for 4 weeks; 357 subjects continued into the open-label period, receiving MFNS only. Between baseline and day 15, significantly greater mean changes were seen with MFNS-treated patients than placebo in physician-evaluated TNSS (-2.8, -39%, vs. -2.2, -32%; p = 0.02). Statistically significant improvements in MFNS versus placebo were reported for subject-evaluated TNSS, TSS, and individual nasal symptom scores (p < or = 0.03 for all). Improvement continued through the open-label period. Subjects treated with MFNS in both periods experienced a 45% further reduction in TSS in this study phase, while those who switched from placebo to MFNS saw a further 49% decrease. MFNS was well-tolerated in both periods. The most frequently reported treatment-related AEs during the double-blind period for MFNS and placebo, respectively, were epistaxis, seven (4%) and nine (5%); sneezing, five (3%) and seven (4%); headache, six (3%) and five (3%). During the open-label period, the AEs reported most often were epistaxis 37 (10%), headache nine (3%), and rhinitis 12 (3%).

LIMITATIONS

Studies in children present unique challenges because subjects are too young to grasp subjective concepts such as symptom severity, especially as rated on a numbered scale. In addition, the 6-month extension of the placebo-controlled phase used a single agent. It is also possible that subjects' symptoms could have abated independent of mometasone furoate treatment.

CONCLUSION

MFNS 100 microg/day effectively reduces TNSS, TSS (including ocular symptoms), and individual symptoms associated with PAR and is well-tolerated for up to 6 months in children aged 3-11 years with a safety profile similar to placebo.

Tryptophan metabolism in allergic rhinitis: the effect of pollen allergen exposure

This study evaluates serum tryptophan, kynurenine, kynurenine-to-tryptophan ratio, and neopterin levels in patients with pollen-induced allergic rhinitis (AR) during and outside of the pollen season, along with these values in healthy subjects. A total of 102 patients (56 female and 46 male, median age 28.7 years) were included in this study: 56 with seasonal AR evaluated outside of the pollen season and thus without allergic inflammation and symptoms, and 46 with seasonal AR evaluated during the pollen season with symptoms. A skin prick test and blood sampling for assessing serum concentrations of tryptophan and kynurenine and of immune activation marker neopterin were performed in all subjects. Tryptophan and kynurenine serum concentrations were higher in AR patients than in controls and were also higher out of pollen season than during this season. In conclusion, this preliminary study demonstrates that serum tryptophan metabolism could serve as a biomarker in patients with AR.

Autologous serum skin test reactivity and basophil histamine release test in patients with nasal polyposis: preliminary results

An eosinophilic inflammatory process is generally observed in patients suffering from nasal polyposis (NP), however its onset has not yet been defined. It has been suggested that immune activation of inflammatory cells may be the cause. The aim of this study is to verify whether autoantibodies and/or histamine-releasing factors are present in the serum of patients suffering from NP. In fact, we assume that autoantibodies and/or histamine-releasing factors, as already demonstrated in chronic idiopathic urticaria and asthma, may be involved in the pathogenesis of NP. In this case-control analytical study 40 patients with NP and 27 control subjects underwent the in vivo autologous serum skin test (ASST). The sera from 6 patients suffering from NP and 9 control group subjects, who had all been previously studied and randomly selected, underwent basophil histamine release assay from normal donor as a pilot study. The ASST showed positive results in 55% of patients suffering from NP versus 8% of the control group (p= .00006), the basophil histamine release test (BHRT) turned out positive in all patients tested and in 11% of the control group. We found a weak positive correlation between the percentage of histamine release and the wheal diameter. ASST reactivity is very frequent in patients suffering from NP, thus suggesting the presence of histamine-releasing factors in the blood stream. The BHRT was positive in the serum of all patients, thus suggesting the presence of anti-FcepsilonRI, anti-IgE autoantibodies and/or other histamine-releasing factors, the presence of which can play a role in triggering and maintaining the eosinophilic inflammatory process in NP.

Mometasone furoate nasal spray reduces the ocular symptoms of seasonal allergic rhinitis

BACKGROUND

Mometasone furoate nasal spray (MFNS), a potent intranasal corticosteroid with proved efficacy in relieving nasal allergic rhinitis symptoms, has demonstrated effectiveness in improving ocular symptoms associated with seasonal allergic rhinitis (SAR) in retrospective analyses.

OBJECTIVE

We sought to evaluate prospectively the efficacy of MFNS in reducing total ocular symptom scores (TOSSs) and individual ocular symptoms in subjects with SAR.

METHODS

Subjects 12 years or older (n = 429) with moderate-to-severe baseline symptoms were randomized to MFNS, 200 microg once daily, or placebo in this 15-day, double-blind, parallel-group study. Subjects evaluated morning instantaneous TOSSs and daily reflective TOSSs, total nasal symptom scores (TNSSs; both instantaneous TNSSs and reflective TNSSs, respectively), and individual ocular and nasal symptoms. Mean changes from baseline averaged over days 2 to 15 (instantaneous) and days 1 to 15 (reflective) were calculated. Quality of life was assessed by using the Rhinoconjunctivitis Quality of Life Questionnaire.

RESULTS

MFNS treatment yielded significant reductions from baseline versus placebo in instantaneous TOSSs (-0.34, P = .026, coprimary end point), instantaneous TNSSs (-0.88, P < .001, coprimary end point), reflective TOSSs (-0.44, P = .005), and reflective TNSSs (-1.06, P < .001). Significant decreases in all individual reflective ocular symptoms and instantaneous eye itching/burning and eye watering/tearing were observed for MFNS versus placebo (P < .05). Numeric improvements in instantaneous eye redness were seen but did not reach statistical significance. Improvements in Rhinoconjunctivitis Quality of Life Questionnaire total scores and individual symptom domains were achieved with MFNS treatment versus placebo (P < .001). MFNS was well tolerated.

CONCLUSION

This prospective study demonstrates that MFNS significantly reduces ocular symptoms in subjects with SAR.

Montelukast treatment may alter the early efficacy of immunotherapy in children with asthma

BACKGROUND

Allergen-specific immunotherapy (SIT) is the only available potentially curative approach in the management of allergic diseases. Therapies that boost regulatory T cell induction during SIT might further enhance its effectiveness.

OBJECTIVE

The purpose of this study was to assess the effect of montelukast treatment on early clinical and immunologic effects of allergen-specific immunotherapy in children with asthma.

METHODS

It was a randomized, double-blind, placebo-controlled trial conducted in 36 children with asthma and allergy to house dust mites who required from 400 to 800 microg of inhaled budesonide per day during the 7-month run-in period. Patients were randomly allocated to receive 5 mg montelukast daily (n = 18) or placebo (n = 18) as an addition to inhaled corticosteroid (ICS) treatment during the 3-month build-up phase of SIT, when modification of ICS doses was not allowed. During the 7 months of the maintenance phase of SIT, ICS doses were adjusted to control the asthma symptoms.

RESULTS

After 12 months of SIT, a reduction of the median daily ICS dose, necessary to control asthma symptoms, was 16.7% grater in patients from the placebo group than in patients from the montelukast group. Intervention with montelukast significantly impaired the induction of regulatory T lymphocytes. During the build-up phase of SIT, patients in the placebo group frequently experienced an increase in asthma symptoms leading to exclusions from the per protocol population.

CONCLUSION

Our study failed to show a beneficial effect of montelukast on SIT. In fact, quite the opposite occurred: compared with placebo, montelukast intervention led to less effectiveness of SIT.

Allergen microarrays on high-sensitivity silicon slides

We have recently introduced a silicon substrate for high-sensitivity microarrays, coated with a functional polymer named copoly(DMA-NAS-MAPS). The silicon dioxide thickness has been optimized to produce a fluorescence intensification due to the optical constructive interference between the incident and reflected lights of the fluorescent radiation. The polymeric coating efficiently suppresses aspecific interaction, making the low background a distinctive feature of these slides. Here, we used the new silicon microarray substrate for allergy diagnosis, in the detection of specific IgE in serum samples of subjects with sensitizations to inhalant allergens. We compared the performance of silicon versus glass substrates. Reproducibility data were measured. Moreover, receiver-operating characteristic (ROC) curves were plotted to discriminate between the allergy and no allergy status in 30 well-characterized serum samples. We found that reproducibility of the microarray on glass supports was not different from available data on allergen arrays, whereas the reproducibility on the silicon substrate was consistently better than on glass. Moreover, silicon significantly enhanced the performance of the allergen microarray as compared to glass in accurately identifying allergic patients spanning a wide range of specific IgE titers to the considered allergens.

Global airway disease beyond allergy

Besides the anatomic continuity of the upper and lower airways, inflammation in one part of the airway influences the homeostasis of the other. The mechanisms underlying this interaction have been studied primarily in allergic disease, showing systemic immune activation, induction of inflammation at a distance, and a negative impact of nasal inflammation on bronchial homeostasis. In addition to allergy, other inflammatory conditions of the upper airways are associated with lower airway disease. Rhinosinusitis is frequently associated with asthma and chronic obstructive pulmonary disease. The impairment of purification, humidification, and warming up of the inspired air by the nose in rhinosinusitis may be responsible in part for bronchial pathology. The resolution of sinonasal inflammation via medical and/or surgical treatment is responsible for the beneficial effect of the treatment on bronchial disease. This article provides a comprehensive overview of the current knowledge of upper and lower airway communication beyond allergic disease.

Allergic conjunctivitis and the impact of allergic rhinitis

Although nasal allergy has been prominent in allergy research, ocular allergy is increasingly recognized as a distinct symptom complex that imposes its own disease burden and reduction in patients' quality of life. In the past year, knowledge of the relationships between allergic conjunctivitis and allergic rhinitis has increased. Allergic conjunctivitis is highly prevalent and has a close epidemiologic relationship with allergic rhinitis. Both conditions also exhibit similar pathophysiologic mechanisms. Pathways of communication are thought to increase the likelihood of an inflammatory reaction at both sites following allergen exposure of nasal or ocular tissue. Clinical trials of intranasal therapies have demonstrated efficacy in allergic conjunctivitis and rhinitis. Newer intranasal steroids decrease ocular symptoms, potentially achieving efficacy by suppressing the naso-ocular reflex, downregulation of inflammatory cell expression, or restoration of nasolacrimal duct patency. Proposed pathophysiologic interactions between allergic rhinitis and ocular allergy underscore the need for therapies with efficacy in both symptom sets.

Occupational rhinitis and asthma: where do we stand, where do we go?

This review provides an overview of current and emerging issues regarding occupational rhinitis (OR) and occupational asthma (OA), focusing on studies discussing concepts and results that are relevant to both diseases. OA and OR are conditions that affect the upper and lower airways, are characterized by reduced airway caliber and hyperresponsiveness and by inflammation, and are caused by agents present in the workplace. To explain disease expression, research is moving from the T-helper type 1/type 2 cells paradigm to consider the contribution of diverse alternative pathways such as neural inflammation, a dysfunctional epithelial barrier, and autoimmune mechanisms, among others. Objective assessment of OR and OA has been improved and tested for research and, currently, clinical application. Further developments in the field of OR are expected to lead to more generalized clinical applications, following the example of what has been achieved for OA.

Protocol for the adolescent hayfever trial: cluster randomised controlled trial of an educational intervention for healthcare professionals for the management of school-age children with hayfever

BACKGROUND

Seasonal allergic rhinitis (hayfever) is common and can contribute to a considerable reduction in the quality of life of adolescents. This study aims to examine the effectiveness of standardised allergy training for healthcare professionals in improving disease-specific quality of life in adolescents with hayfever.

METHODS/DESIGN

Adolescents with a history of hayfever registered in general practices in Scotland and England were invited to participate in a cluster randomised controlled trial. The unit of randomisation is general practices.The educational intervention for healthcare professionals consists of a short standardised educational course, which focuses on the management of allergic rhinitis. Patients in the intervention arm of this cluster randomised controlled trial will have a clinic appointment with their healthcare professional who has attended the training course. Patients in the control arm will have a clinic appointment with their healthcare professional and will receive usual care. The primary outcome measure is the change in the Rhinoconjunctivitis Quality of Life Questionnaire with Standardised Activities (RQLQ(S)) score between baseline and six weeks post-intervention in the patient intervention and control groups. Secondary outcome measures relate to healthcare professionals' understanding and confidence in managing allergic rhinitis, changes in clinical practice, numbers of consultations for hayfever and adolescent exam performance.A minimum of 11 practices in each arm of the trial (10 patients per cluster) will provide at least 80% power to demonstrate a minimal clinically important difference of 0.5 in RQLQ(S) score at a significance level of 5% based on an Intraclass Correlation Coefficient (ICC) of 0.02.

DISCUSSION

At the time of submission, 24 general practices have been recruited (12 in each arm of the trial) and the interventions have been delivered. Follow-up data collection is complete. 230 children consented to take part in the trial; however complete primary outcome data are only available for 160. Further recruitment of general practices and patients will therefore take place in the summer of 2010.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN95538067.

Specific recommendations for PROs and HRQoL assessment in allergic rhinitis and/or asthma: a GA(2)LEN taskforce position paper

The GA(2)LEN taskforce on Patient-Reported Outcomes (PROs) and Health-Related Quality of Life (HRQoL) published in 2009 a position paper concerning PROS and HRQoL assessment in clinical trials on allergy. Because of the specificity of this topic in asthma and rhinitis, specific recommendations are needed. The aim of this position paper is to define PROs and their meaning in asthma and rhinitis research, explore the available tools to provide criteria for a proper choice, identify patient-related factor which could influence PROs assessment, define specific recommendations for assessment, analysis and results spreading, underline the unexplored areas and unmet needs. PROs assessment is gaining increasing importance, and it must be performed with a rigorous methodological procedure and using validated tools. This approach enables to better understand patient-related factors influencing clinical trials and real-life management outcomes, identify patients subgroups that can benefit from specific treatment and management plan and tailor treatment to address PROs (not only physician-defined targets) to improve asthma and rhinitis management.

Validation of a questionnaire (CARAT10) to assess rhinitis and asthma in patients with asthma

BACKGROUND AND AIM

The Control of Allergic Rhinitis and Asthma Test (CARAT) was developed to be used in the concurrent management of these diseases, as recommended by the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines. However, it was necessary to statistically identify and remove redundant questions and to evaluate the new version's factor structure, internal consistency and concurrent validity.

METHODS

In this cross-sectional study 193 adults with allergic rhinitis and asthma from 15 outpatient clinics in Portugal were included. The CARAT questionnaire was reduced using descriptive analysis, exploratory factor analysis and internal consistency. Spearman's correlations were used to compare the CARAT scores with a medical evaluation and other measures of control, including the Asthma Control Questionnaire and symptoms' visual analogue scales. The performance against physician rating of control was summarized using the area under the curve (AUC) from receiver operating characteristic analysis. In addition, CARAT was compared with the physician's decision to reduce, maintain or increase treatment.

RESULTS

The reduced version has 10 questions and 2 factors (CARAT10). The Cronbach's alpha was 0.85. All correlation coefficients of CARAT10 and factors with the different measures of control met the a priori predictions, ranging from 0.58 to 0.79. The AUC was 0.82. For the physician's decision groups of reduce, maintain or increase treatment, the mean (IC95%) scores of CARAT10 were 24 (21.4;26.6), 21 (19.4;21.9) and 15 (13.6;16.5), respectively.

CONCLUSION

CARAT10 has high internal consistency and good concurrent validity, making it useful to compare groups in clinical studies.

Transient hypogammaglobulinemia and unclassified hypogammaglobulinemia: 'similarities and differences'

Transient hypogammaglobulinemia of infancy (THI) is characterized by recurrent infections and one or more reduced serum immunoglobulin (Ig) levels. Usually, this clinical picture resolves spontaneously by 3 yr of age. However, hypogammaglobulinemia persists until adolescence in some patients. In recent years, those patients have been classified as undefined/unclassified hypogammaglobulinemia (UCH). We aimed to evaluate the clinical and immunologic features of patients with THI and UCH considering age of recovery and to assess relationships between hypogammaglobulinemia, infections, and allergic manifestations. We reviewed the medical records of children followed with a diagnosis of hypogammaglobulinemia from 2001 to 2007. Patients with decreased levels (<2 s.d.) of one or more major Ig isotypes (IgG, IgA, IgM) with normal antibody responses and lymphocyte subpopulations were included (n = 374). Those patients whose Igs normalized during the follow-up period were classified as THI and the others as UCH. The THI group consisted of 71 patients (27 females, 44 males) with a mean recovery age of 68.87 +/- 36.5 months. About 95% of patients with THI recovered before 10 yr of age. The UCH group consisted of 303 patients (105 females, 198 males) with a mean age at diagnosis of 52 +/- 42 months. The most common presenting manifestations in the THI and UCH groups were upper respiratory tract infections (URTIs), lower respiratory tract infections, and asthma (42%, 50%, and 52% in the THI group vs. 39%, 53%, and 55% in the UCH group, respectively). In the THI group, the prevalence of atopic disease was related to age and found to be increased markedly after 44 months. In all patients, the prevalence of asthma was independently and positively associated with family history of atopy and age, whereas it was negatively associated with recurrent URTIs. Patients with THI and UCH have similar clinical and immunologic features. The normalization of Igs may be delayed in a majority of the patients with hypogammaglobulinemia. This observation may be a contribution to the classical definition and diagnostic criteria for THI.