National prevalence of respiratory allergic disorders

European pollen reanalysis, 1980-2022, for alder, birch, and olive

The dataset presents a 43 year-long reanalysis of pollen seasons for three major allergenic genera of trees in Europe: alder (Alnus), birch (Betula), and olive (Olea). Driven by the meteorological reanalysis ERA5, the atmospheric composition model SILAM predicted the flowering period and calculated the Europe-wide dispersion pattern of pollen for the years 1980-2022. The model applied an extended 4-dimensional variational data assimilation of in-situ observations of aerobiological networks in 34 European countries to reproduce the inter-annual variability and trends of pollen production and distribution. The control variable of the assimilation procedure was the total pollen release during each flowering season, implemented as an annual correction factor to the mean pollen production. The dataset was designed as an input to studies on climate-induced and anthropogenically driven changes in the European vegetation, biodiversity monitoring, bioaerosol modelling and assessment, as well as, in combination with intra-seasonal observations, for health-related applications.

Poor Rhinitis and Asthma Control Is Associated With Decreased Health-Related Quality of Life and Utilities: A MASK-air Study

BACKGROUND

Allergic rhinitis (AR) and asthma may affect health-related quality of life. However, national estimates on the quality of life of patients with AR or asthma are lacking.

OBJECTIVE

To provide estimates for utility scores and EuroQoL five-dimension (EQ-5D) visual analog scale (VAS) for patients with AR or asthma.

METHODS

We conducted a cross-sectional study using direct patient data from the MASK-air app on European MASK-air users with self-reported AR or asthma. We used a multi-attribute instrument (EQ-5D) to measure quality of life (as utility scores and EQ-5D VAS values). Mean scores were calculated per country and disease control level using multilevel regression models with poststratification, accounting for age and sex biases.

RESULTS

We assessed data from 7905 MASK-air users reporting a total of up to 82,737 days. For AR, utilities ranged from 0.86 to 0.99 for good control versus 0.72 to 0.85 for poor control; EQ-5D VAS levels ranged from 78.9 to 87.9 for good control versus 55.3 to 64.2 for poor control. For asthma, utilities ranged from 0.84 to 0.97 for good control versus 0.73 to 0.87 for poor control; EQ-5D VAS levels ranged from 68.4 to 81.5 for good control versus 51.4 to 64.2 for poor control. Poor disease control was associated with a mean loss of 0.14 utilities for both AR and asthma. For the same control levels, AR and asthma were associated with similar utilities and EQ-5D VAS levels. However, lower values were observed for asthma plus AR compared with AR alone.

CONCLUSIONS

Poor AR or asthma control are associated with reduced quality of life. The estimates obtained from mobile health data may provide valuable insights for health technology assessment studies.

The MaDo real-life study of dose adjustment of allergen immunotherapy liquid formulations in an indication of respiratory allergic disease: Reasons, practices, and outcomes

Sublingual allergen immunotherapy (SLIT) is a safe, effective, disease-modifying treatment for moderate-to-severe respiratory allergies. The function and responsiveness of the immune system components underlying the effects of allergen immunotherapy may vary from one patient to another. Furthermore, the severity of the symptoms of allergic disease can fluctuate over time, due to changes in environmental allergen exposure, effector cell responsiveness, and cell signaling. Hence, the allergen dose provided through SLIT can be fine-tuned to establish an optimal balance between effectiveness and tolerability. The objective of the MaDo study was to describe and understand dose adjustments of SLIT liquid formulations in France. We performed a retrospective, observational, cross-sectional, real-life study of allergists and other specialist physicians. Physicians described their patients via an anonymous case report form (CRF). The main patient inclusion criteria were age 5 years or over, at least one physician-confirmed IgE-driven respiratory allergy, and treatment for at least 2 years with one or more SLIT liquid preparations. A nationally representative sample of 33 specialist physicians participated in the study. The physicians' main stated reasons for dose adjustment were adverse events (according to 90.9% of the physicians), treatment effectiveness (60.6%), sensitivity to the allergen (42.4%) and other characteristics (30.3%: mainly symptom severity, type of allergen, and asthma). 392 CRFs (mean ± standard deviation patient age: 27.8 ± 17.5; under-18s: 42.1%; polyallergy: 30.9%) were analyzed. Respectively 53.6%, 25.8%, 15.3%, and 8.7% of the patients received house dust mite, grass pollen, birch pollen and cypress pollen SLIT. Dose adjustments were noted in 258 (65.8%) patients (at the start of the maintenance phase for 101 patients (39.2%) and later for 247 (95.7%)). Dose adjustment was not linked to sex, age, or the number of allergens administered. All measures of disease severity (including symptom severity noted on a 0-to-10 visual analogue scale by the physician) decreased significantly during SLIT. Notably, the mean AR symptom severity score decreased to a clinically relevant extent from 7.6 at SLIT initiation to 2.4 at last follow-up, and the mean asthma symptom severity score decreased from 5.0 to 1.3. The few differences in effectiveness between patients with vs. without dose adjustment were not major. For about one patient in five, a specialist physician decided to reduce or increase the SLIT liquid dose at the start of maintenance treatment and/or during maintenance treatment. This decision was influenced by a broad range of patient and treatment factors, mainly to improve tolerability to treatment and/or enhance effectiveness. In France, dose adjustment of SLIT liquid preparations as a function of the patient profile and/or treatment response is anchored in clinical practice. Precision dosing might optimize the overall benefit-risk profile of AIT for individual patients throughout their entire treatment course, enabling them to achieve both short- and long-term treatment goals, whilst maximizing the safety and tolerability.

Long-Term Pollen Monitoring in the Benelux: Evaluation of Allergenic Pollen Levels and Temporal Variations of Pollen Seasons

Airborne pollen is a major cause of allergic rhinitis, affecting between 10 and 30% of the population in Belgium, the Netherlands, and Luxembourg (Benelux). Allergenic pollen is produced by wind pollinating plants and released in relatively low to massive amounts. Current climate changes, in combination with increasing urbanization, are likely to affect the presence of airborne allergenic pollen with respect to exposure intensity, timing as well as duration. Detailed analysis of long-term temporal trends at supranational scale may provide more comprehensive insight into these phenomena. To this end, the Spearman correlation was used to statistically compare the temporal trends in airborne pollen concentration monitored at the aerobiological stations which gathered the longest time-series (30–44 years) in the Benelux with a focus on the allergenic pollen taxa: Alnus, Corylus, Betula, Fraxinus, Quercus, Platanus, Poaceae, and Artemisia. Most arboreal species showed an overall trend toward an increase in the annual pollen integral and peak values and an overall trend toward an earlier start and end of the pollen season, which for Betula resulted in a significant decrease in season length. For the herbaceous species (Poaceae and Artemisia), the annual pollen integral and peak values showed a decreasing trend. The season timing of Poaceae showed a trend toward earlier starts and longer seasons in all locations. In all, these results show that temporal variations in pollen levels almost always follow a common trend in the Benelux, suggesting a similar force of climate change-driven factors, especially for Betula where a clear positive correlation was found between changes in temperature and pollen release over time. However, some trends were more local-specific indicating the influence of other environmental factors, e.g., the increasing urbanization in the surroundings of these monitoring locations. The dynamics in the observed trends can impact allergic patients by increasing the severity of symptoms, upsetting the habit of timing of the season, complicating diagnosis due to overlapping pollen seasons and the emergence of new symptoms due allergens that were weak at first.

Basophil sensitivity reflects long-term clinical outcome of subcutaneous immunotherapy in grass pollen-allergic patients

BACKGROUND

Allergic rhinoconjunctivitis is a public health problem. Allergen Immunotherapy is an effective and safe treatment, that modifies the natural course of allergic disease and induces long-term tolerance.

OBJECTIVE

To correlate basophil and antibody biomarkers of subcutaneous immunotherapy to clinical outcomes and cellular changes in target tissue.

METHODS

Adults suffering from allergic rhinoconjunctivitis due to grass pollen allergy were randomized to receive subcutaneous immunotherapy (n = 18) or to an open control group (n = 6). Patients reported daily symptom and medication scores and weekly rhinitis related quality of life scores during four pollen seasons. Biomarkers were measured every 3 months for three years treatment and every 6 months in the follow-up year. Nasal and cutaneous allergen challenge tests were performed annually. Leukocyte subsets were assessed in nasal mucosa biopsies at baseline and after treatment.

RESULTS

Subcutaneous immunotherapy led to a 447-fold decrease in basophil sensitivity during the first treatment year. This remained 100-fold lower than baseline during the 3 year-treatment period and 10-fold lower during the follow-up year (n = 18, P = .03). Decrease in basophil sensitivity after three weeks of treatment predicted long-term improvement in seasonal combined symptom and medication scores (ῥ=-0.69, P = .0027) during three years of treatment. AUC of IgE-blocking factor correlated to nasal allergen challenge (ῥ = 0.63, P = .0012) and SPT (ῥ = 0.45, P = .03). Plasma cell numbers in the nasal mucosa increased during treatment (P = .02).

CONCLUSION

Decrease in basophil sensitivity after three weeks of subcutaneous allergen immunotherapy predicted the clinical outcome of this treatment.

Toxoplasma gondii, Suicidal Behavior, and Intermediate Phenotypes for Suicidal Behavior

Within the general literature on infections and suicidal behavior, studies on Toxoplasma gondii (T. gondii) occupy a central position. This is related to the parasite's neurotropism, high prevalence of chronic infection, as well as specific and non-specific behavioral alterations in rodents that lead to increased risk taking, which are recapitulated in humans by T. gondii's associations with suicidal behavior, as well as trait impulsivity and aggression, mental illness and traffic accidents. This paper is a detailed review of the associations between T. gondii serology and suicidal behavior, a field of study that started 15 years ago with our publication of associations between T. gondii IgG serology and suicidal behavior in persons with mood disorders. This "legacy" article presents, chronologically, our primary studies in individuals with mood disorders and schizophrenia in Germany, recent attempters in Sweden, and in a large cohort of mothers in Denmark. Then, it reviews findings from all three meta-analyses published to date, confirming our reported associations and overall consistent in effect size [ranging between 39 and 57% elevation of odds of suicide attempt in T. gondii immunoglobulin (IgG) positives]. Finally, the article introduces certain links between T. gondii and biomarkers previously associated with suicidal behavior (kynurenines, phenylalanine/tyrosine), intermediate phenotypes of suicidal behavior (impulsivity, aggression) and state-dependent suicide risk factors (hopelessness/dysphoria, sleep impairment). In sum, an abundance of evidence supports a positive link between suicide attempts (but not suicidal ideation) and T. gondii IgG (but not IgM) seropositivity and serointensity. Trait impulsivity and aggression, endophenotypes of suicidal behavior have also been positively associated with T. gondii seropositivity in both the psychiatrically healthy as well as in patients with Intermittent Explosive Disorder. Yet, causality has not been demonstrated. Thus, randomized interventional studies are necessary to advance causal inferences and, if causality is confirmed, to provide hope that an etiological treatment for a distinct subgroup of individuals at an increased risk for suicide could emerge.

The Impact of Climate Change on Pollen Season and Allergic Sensitization to Pollens

Pollens are a major cause of seasonal allergic diseases. Weather may alter the production of pollens. Increased atmospheric temperatures lead to earlier pollination of many plants and longer duration of pollination, resulting in extended pollen seasons, with early spring or late winter. Longer pollen seasons increase duration of exposure, resulting in more sensitization, and higher pollen concentrations may lead to more severe symptoms. Climate changes in contact to pollens may affect both allergic sensitization and symptom prevalence with severity. The future consequences of climate change, however, are speculative, because the influence on humans, is complex.

Relevant Patient Benefit of Sublingual Immunotherapy with Birch Pollen Allergen Extract in Allergic Rhinitis: An Open, Prospective, Non-Interventional Study

INTRODUCTION

Sublingual immunotherapy (SLIT) with birch pollen extract has been shown to be an efficacious treatment of allergic rhinitis (AR). An as-yet unanswered question is whether and how clinical benefit translates into patient benefit, i.e. what benefit patients derive from this treatment.

METHODS

This 1-year, open, prospective, multicenter, non-interventional study conducted in 75 German centers measured patient-relevant benefit of birch pollen SLIT (Staloral^® Birch) using the questionnaire "Patient Benefit Index for Allergic Rhinitis (PBI-AR)". At treatment onset, patients rated the importance of 25 treatment needs; after the first birch pollen season on treatment, goal achievement was evaluated. A preference-weighted benefit index was calculated and its association with gender, asthma, allergy status, and severity of AR symptoms was determined.

RESULTS

Mean age of the 291 adult patients was 38.8 years; 58.4% were female. The most important treatment goals were to "be able to stay outdoors without symptoms" (87.3% quite or very important), "no longer have a runny or stuffed-up nose" (86.9%), and "be able to breathe through your nose more freely" (86.9%). The treatment goals with the highest benefit ratings (referring to those patients to whom the respective goal applied) were to "have confidence in the therapy" (60.5% has helped "quite" or "very much"), "have an easily applicable treatment" (55.6%), and "be able to breathe through my nose more freely" (51.7%). The average PBI-AR global score was 2.19 (SD 1.04) (0-4; with 4 indicating maximum benefit). No significant differences in PBI-AR global score or subscales were found between men and women, poly- and monoallergic patients, or patients with severe versus mild rhinoconjunctivitis. Patients with asthma reported relevant but lower benefit than patients without asthma.

CONCLUSION

After 1 year of birch pollen SLIT treatment, patients reported considerable benefit, mainly due to a reduction of physical symptoms and treatment burden.

Sensitization profile in patients with respiratory allergic diseases: differences between conventional and molecular diagnosis (a cross-sectional study)

Background

Component-resolved diagnosis (CRD) allows to identify single molecular allergen components, and constitutes a routine practice in many allergy units. However, skin prick test (SPT) remains the technique of choice in many otorhinolaryngology departments, thus increasing the risk of using inadequate immunotherapies in patients with respiratory allergies. This study aimed to compare sensitization profiles determined by SPT and CRD in patients with respiratory allergy, and to explore the relationship between sensitization and type and severity of the respiratory disease.

Methods

Cross-sectional, multicenter study of patients admitted to the Otorhinolaryngology Department due to symptoms of respiratory allergy. Extracts from various house dust mites, pollens, and molds were tested by SPT, whereas IgE against the corresponding antigens were measured by CRD.

Results

The analysis included 101 patients. The sensitization profile obtained by SPT had low agreement with that of CRD, particularly to dust mite allergens (Dermatophagoides sp.) and pollens (Plantago lanceolata, Olea europaea, and Cupressus sempervirens). While SPT did not show any significant relationship between sensitization and type/severity of the respiratory disease, CRD allowed to associate Der p 1, Der f 1 and Lep d 2 sensitizations with asthma, and Der p 2, Der f 2 and Lep d 2 sensitizations with more severe symptoms of allergic rhinitis.

Conclusions

Compared with SPT, CRD enables to describe a more accurate sensitization profile and to identify associations between symptoms and specific antigens. The routine use of CRD in an otorhinolaryngology setting may benefit the management of patients with respiratory allergy.Trial registration IB 3108/15 (Retrospectively registered).

Mucosal bromodomain-containing protein 4 mediates aeroallergen-induced inflammation and remodeling

BACKGROUND

Frequent exacerbations of allergic asthma lead to airway remodeling and a decrease in pulmonary function, producing morbidity. Cat dander is an aeroallergen associated with asthma risk.

OBJECTIVE

We sought to elucidate the mechanism of cat dander-induced inflammation-remodeling.

METHODS

We identified remodeling in mucosal samples from allergic asthma by using quantitative RT-PCR. We developed a model of aeroallergen-induced experimental asthma using repetitive cat dander extract exposure. We measured airway inflammation using immunofluorescence, leukocyte recruitment, and quantitative RT-PCR. Airway remodeling was measured by using histology, collagen content, myofibroblast numbers, and selected reaction monitoring. Inducible nuclear factor κB (NF-κB)-BRD4 interaction was measured by using a proximity ligation assay in situ.

RESULTS

Enhanced mesenchymal signatures are observed in bronchial biopsy specimens from patients with allergic asthma. Cat dander induces innate inflammation through NF-κB signaling, followed by production of a profibrogenic mesenchymal transition in primary human small airway epithelial cells. The IκB kinase-NF-κB signaling pathway is required for mucosal inflammation-coupled airway remodeling and myofibroblast expansion in the mouse model of aeroallergen exposure. Cat dander induces NF-κB/RelA to complex with and activate BRD4, resulting in modifying the chromatin environment of inflammatory and fibrogenic genes through its atypical histone acetyltransferase activity. A novel small-molecule BRD4 inhibitor (ZL0454) disrupts BRD4 binding to the NF-κB-RNA polymerase II complex and inhibits its histone acetyltransferase activity. ZL0454 prevents epithelial mesenchymal transition, myofibroblast expansion, IgE sensitization, and fibrosis in airways of naive mice exposed to cat dander.

CONCLUSIONS

NF-κB-inducible BRD4 activity mediates cat dander-induced inflammation and remodeling. Therapeutic modulation of the NF-κB-BRD4 pathway affects allergen-induced inflammation, epithelial cell-state changes, extracellular matrix production, and expansion of the subepithelial myofibroblast population.

High-throughput screening of T7 phage display and protein microarrays as a methodological approach for the identification of IgE-reactive components

Olive pollen and yellow mustard seeds are major allergenic sources with high clinical relevance. To aid with the identification of IgE-reactive components, the development of sensitive methodological approaches is required. Here, we have combined T7 phage display and protein microarrays for the identification of allergenic peptides and mimotopes from olive pollen and mustard seeds. The identification of these allergenic sequences involved the construction and biopanning of T7 phage display libraries of mustard seeds and olive pollen using sera from allergic patients to both biological sources together with the construction of phage microarrays printed with 1536 monoclonal phages from the third/four rounds of biopanning. The screening of the phage microarrays with individual sera from allergic patients enabled the identification of 10 and 9 IgE-reactive unique amino acid sequences from olive pollen and mustard seeds, respectively. Five immunoreactive amino acid sequences displayed on phages were selected for their expression as His6-GST tag fusion proteins and validation. After immunological characterization, we assessed the IgE-reactivity of the constructs. Our results show that protein microarrays printed with T7 phages displaying peptides from allergenic sources might be used to identify allergenic components -peptides, proteins or mimotopes- through their screening with specific IgE antibodies from allergic patients.

IgG4-related disease in Italy: clinical features and outcomes of a large cohort of patients

OBJECTIVES

To describe the clinical features, treatment response, and follow-up of a large cohort of Italian patients with immunoglobulin (Ig)G4-related disease (IgG4-RD) referred to a single tertiary care centre.

METHOD

Clinical, laboratory, histological, and imaging features were retrospectively reviewed. IgG4-RD was classified as 'definite' or 'possible' according to international consensus guidelines and comprehensive diagnostic criteria for IgG4-RD. Disease activity was assessed by means of the IgG4-RD Responder Index (IgG4-RD RI).

RESULTS

Forty-one patients (15 females, 26 males) were included in this study: 26 with 'definite' IgG4-RD and 15 with 'possible' IgG4-RD. The median age at diagnosis was 62 years. The median follow-up was 36 months (IQR 24-51). A history of atopy was present in 30% of patients. The pancreas, retroperitoneum, and major salivary glands were the most frequently involved organs. Serum IgG4 levels were elevated in 68% of cases. Thirty-six patients were initially treated with glucocorticoids (GCs) to induce remission. IgG4-RD RI decreased from a median of 7.8 at baseline to 2.9 after 1 month of therapy. Relapse occurred in 19/41 patients (46%) and required additional immunosuppressive drugs to maintain long-term remission. Multiple flares occurred in a minority of patients. A single case of orbital pseudotumour did not respond to medical therapy and underwent surgical debulking.

CONCLUSIONS

IgG4-RD is an elusive inflammatory disease to be considered in the differential diagnosis of isolated or multiple tumefactive lesions. Long-term disease control can be achieved with corticosteroids and immunosuppressive drugs in the majority of cases.

The Prevalence, Risk Factors and Changes in Symptoms of Self Reported Asthma, Rhinitis and Eczema Among Pregnant Women in Ogbomoso, Nigeria

BACKGROUND

Allergic disorders have become a major public health concern worldwide. No Nigerian study has examined the epidemiology of allergic diseases among women.

AIM

To document the prevalence, risk factors and the changes in the symptoms of allergic disorders during pregnancy.

SETTINGS AND DESIGN

Cross-sectional study conducted at the booking and antenatal clinics of LAUTECH Teaching Hospital and Millennium Development Goals (MDG) Clinic of the Comprehensive Health Center, Oja Igbo, Ogbomoso, Nigeria.

MATERIALS AND METHODS

Study enrolled 432 women from two public hospitals. Sociodemographic and clinical history were obtained and allergic disorders were diagnosed using ISAAC questionnaires.

RESULTS

The prevalence of wheezing, eczema and rhinitis in pregnancy are 7.5%, 4.0% and 5.8% respectively. The prevalence of wheezing and eczema was slightly higher among the pregnant in past 12 months. Wheeze worsened in 70% (18/26), improved in 15% (2/26), and stable in 15% (2/26). Eczema worsened in 50% (7/14), improved in 7.1% (1/14) and stable in 42.9% (6/14), while allergic rhinitis worsened in 50% (11/22), improved in 22.7% (5/22) and stabilized in 27.3 % (6/22). In multivariate analysis, the risk of allergic diseases in pregnancy was increase 2 times by low income earning (CI: 1.2 - 2.1, p = 0.002), low level education (OR = 0.6, CI: 0.3 - 0.9, p = 0.011) and by family history of asthma, OR-4.3, CI - 1.3 - 13.9, p = 0.015. Family history of asthma increase the chances of asthma by 18.7 times, CI-2.3 - 152.2, p = 0.006, while the odd of eczema was increased 9.1 times (CI-2.7 - 30.6, p<0.001) and 2.4 times (CI: 1.2 - 4.7, p = 0.008) by second hand home smoking and low-family income respectively. The risk of allergic rhinitis were raised 1.8 times by low family income (CI 1.1 - 2.8, p = 0.013) and 3.9 times by family history of rhinitis (OR = 3.9, CI 1.2 - 12.7, p = 0.024).

CONCLUSION

Prevalence of wheezing and eczema are higher in pregnancy probably due to exacerbation induced by pregnancy. Social and genetic factors are important risk factors for allergic disorders in pregnancy.

An Enzymatically Active β-1,3-Glucanase from Ash Pollen with Allergenic Properties: A Particular Member in the Oleaceae Family

Endo-β-1,3-glucanases are widespread enzymes with glycosyl hydrolitic activity involved in carbohydrate remodelling during the germination and pollen tube growth. Although members of this protein family with allergenic activity have been reported, their effective contribution to allergy is little known. In this work, we identified Fra e 9 as a novel allergenic β-1,3-glucanase from ash pollen. We produced the catalytic and carbohydrate-binding domains as two independent recombinant proteins and characterized them from structural, biochemical and immunological point of view in comparison to their counterparts from olive pollen. We showed that despite having significant differences in biochemical activity Fra e 9 and Ole e 9 display similar IgE-binding capacity, suggesting that β-1,3-glucanases represent an heterogeneous family that could display intrinsic allergenic capacity. Specific cDNA encoding Fra e 9 was cloned and sequenced. The full-length cDNA encoded a polypeptide chain of 461 amino acids containing a signal peptide of 29 residues, leading to a mature protein of 47760.2 Da and a pI of 8.66. An N-terminal catalytic domain and a C-terminal carbohydrate-binding module are the components of this enzyme. Despite the phylogenetic proximity to the olive pollen β-1,3-glucanase, Ole e 9, there is only a 39% identity between both sequences. The N- and C-terminal domains have been produced as independent recombinant proteins in Escherichia coli and Pichia pastoris, respectively. Although a low or null enzymatic activity has been associated to long β-1,3-glucanases, the recombinant N-terminal domain has 200-fold higher hydrolytic activity on laminarin than reported for Ole e 9. The C-terminal domain of Fra e 9, a cysteine-rich compact structure, is able to bind laminarin. Both molecules retain comparable IgE-binding capacity when assayed with allergic sera. In summary, the structural and functional comparison between these two closely phylogenetic related enzymes provides novel insights into the complexity of β-1,3-glucanases, representing a heterogeneous protein family with intrinsic allergenic capacity.

Asthma and the otolaryngologist

BACKGROUND

Asthma is a chronic inflammatory disease of the lower airway that is commonly encountered by the otolaryngologist. This article provides information on how to recognize patients with asthma and discuss issues related to diagnosis, treatment, and continued management within the context of current guidelines.

METHODS

A literature review was conducted and relevant sources are referenced concerning the epidemiology of asthma, the pathophysiology of asthma, diagnostic strategies, treatment options, and continued management.

RESULTS

Asthma is a common condition worldwide and is often associated with other atopic diseases such as allergic rhinitis and eczema, though other genetic and environmental factors appear to be important as well. The lower airway and upper airways share similar histology, as well as patterns of inflammation in response to environmental triggers. The diagnosis of asthma involves a careful history and a complete physical exam, including auscultation of the lungs and pulmonary function testing. Pharmacotherapy represents the primary method of treating asthma, though current evidence supports a positive role for antigen-specific immunotherapy for both prevention and treatment. Guidelines are available that can assist the otolaryngologist in classifying the severity of asthma, determining the level of control and recommending modifications in the treatment plan.

CONCLUSION

As airway specialists, otolaryngologists are in a unique position to recognize and manage asthma in their patients, particularly those with allergic disease. Maintaining a high index of suspicion and understanding the key elements of diagnosis and treatment are extremely important in order to achieve this goal.

Sustained effect of grass pollen subcutaneous immunotherapy on suppression of allergen-specific basophil response; a real-life, nonrandomized controlled study

BACKGROUND

An important advantage of allergen immunotherapy as compared to pharmacotherapy for allergic rhinitis is the long-term effect that persists after completing immunotherapy. The mechanism of the sustained effect of allergen immunotherapy is not completely understood.

METHODS

We conducted a 7-year study of monitoring allergen-specific basophil response and serological markers in 20 subjects with moderate-to-severe grass pollen-allergic rhinitis just before beginning and after up-dosing of subcutaneous grass pollen immunotherapy, before the first pollen season, and 1-2 years after completion of 3-5 years of treatment. Comparable untreated rhinitis subjects were followed at the same time points. Clinical outcomes included assessment of symptoms, use of rescue medication, and quality of life. The basophil response was also monitored after removal of IgG antibodies.

RESULTS

Basophil response assessed as area under the curve (AUC) halved during initiation of SCIT and was 55% lower 1-2 years after completing SCIT. In the untreated group, the basophil response remained comparable. Although immunotherapy-induced grass pollen-specific IgG4 levels decreased to near pre-immunotherapy levels after completing SCIT, the removal of IgG antibodies resulted in an increase in basophil response almost to the pre-immunotherapy levels. In untreated subjects, removal of IgG did not have any effect on basophil response.

CONCLUSIONS

Grass pollen immunotherapy induces sustained suppression of the allergen-specific basophil response that persists after completion of treatment and could account for long-term clinical tolerance. It also seems to be associated with persistent blocking activity of IgG antibodies.

Diagnosis and allergen immunotherapy treatment of polysensitised patients with respiratory allergy in Spain: an Allergists' Consensus

BACKGROUND

Polysensitisation is common in patients with respiratory allergy in Spain. Selection of the best allergen immunotherapy (AIT) is difficult in polysensitised patients. The present study was designed to help allergists better identify relevant allergens in these patients and to improve the selection of AIT in Spain.

METHODS

Sixty-two Spanish allergists answered a survey containing 88 items divided into four groups: 1) general approach to polysensitised subjects; 2) sensitisation profile involving mite, animal dander and moulds; 3) grass and olive pollen co-sensitisation, and 4) other pollen polysensitisation profile (weed and tree pollen). The Delphi method was used.

RESULTS

A consensus was achieved for 83% of items (92%, 81%, 83% and 73% of the four groups analysed, respectively). Only polysensitised patients with clinical relevance should be considered polyallergic. A detailed medical history (clinical symptoms and medication) together with a profound knowledge of allergens present in the patient's environment are essential for diagnosis. Skin prick tests (SPTs) are not adequate to decide the clinical relevance of each allergen. Serum specific IgE against allergen sources adds value to SPT but molecular diagnosis, when possible, is strongly recommended, especially in pollen-allergic patients. Specific allergen challenge tests are difficult to perform and not recommended for daily practice. Regarding AIT composition, up to three allergens can be used in the same vaccine, but only related allergens may be mixed. In some cases more than one vaccine may be needed.

CONCLUSION

Some criteria have been established to improve diagnosis and AIT prescription in polysensitised patients.

Why otolaryngologists and asthma are a good match: the allergic rhinitis-asthma connection

Consideration of the unified airway model when managing patients with rhinitis and or asthma allows a more comprehensive care plan and therefore improved patient outcomes. Asthma is linked to rhinitis both epidemiologically and biologically, and this association is even stronger in individuals with atopy. Rhinitis is not only associated with but is a risk factor for the development of asthma. Management of rhinitis improves asthma control. Early and aggressive treatment of allergic rhinitis may prevent the development of asthma. In patients with allergic rhinitis that is not sufficiently controlled by allergy medication, allergen-directed immunotherapy should be considered.

Estimation of health-related utility (EQ-5D index) in subjects with seasonal allergic rhinoconjunctivitis to evaluate health gain associated with sublingual grass allergen immunotherapy

Background

Grass allergen immunotherapy (AIT) reduces symptom severity in seasonal allergic rhinoconjunctivitis (ARC) but its impact on general health-related utility has not been characterised for the purposes of economic evaluation. The aim of this study was to model the preferred measure of utility, EQ-5D index, from symptom severity and estimate incremental quality adjusted life years (QALYs) associated with SQ-standardised grass immunotherapy tablet (GRAZAX®, 75,000 SQ-T/2,800 BAU, ALK, Denmark).

Methods

Data were analysed from five consecutive pollen seasons in a randomised placebo controlled trial of GRAZAX®. Binomial and Gaussian mixed effects modelling related weekly EQ-5D index score to daily symptom and medication scores (DSS & DMS respectively). In turn, daily EQ-5D index was estimated from ARC symptoms and medication use.

Results

DSS and DMS were the principal predictors of ‘perfect’ health (EQ-5D = 1.000; binomial) and ‘imperfect’ health (EQ-5D < 1.000; Gaussian). Each unit increase in DSS and DMS reduced the odds of ‘perfect’ health (EQ-5D = 1.000) by 27% and 16% respectively, and reduced ‘imperfect’ health by 0.17 and 0.13, respectively. Gender remained the only other significant main fixed effect (Male odds ratio [OR] = 1.82). Incremental estimated EQ-5D index utility for GRAZAX® was observed from day -30 to day +70 of the pooled pollen season; mean daily utility for GRAZAX® = 0.938 units (95%CI 0.932-0.943) vs. 0.914 (0.907-0.921) for placebo, an incremental difference of 0.0238 (p < 0.001). This translates into an incremental 0.0324 Quality Adjusted Life Years over the five year study period.

Conclusions

ARC symptoms and medication use are the main predictors of EQ-5D index. The incremental QALYs observed for GRAZAX® may not fully describe the health benefits of this treatment, suggesting that economic modelling may be conservative.

The role of the γ δ T cell in allergic diseases

The predominant distribution of γδ T cells in the mucosal and epithelial tissues makes these unconventional lymphocytes the “guards” to contact external environment (like allergens) and to contribute to immune surveillance, as well as “vanguards” to participate in initiating mucosal inflammation. Therefore, γδ T cells have been considered to bridge the innate and adaptive immunity. The role these cells play in allergy seems to be complicated and meaningful, so it makes sense to review the characteristics and role of γδ T cells in allergic diseases.

Patient related outcomes in a real life prospective follow up study: Allergen immunotherapy increase quality of life and reduce sick days

BACKGROUND

One fourth of the adult population in Europe suffer from respiratory allergy. Subcutaneous-allergen-specific-immunotherapy (SCIT) has long-term disease modifying effect on disease specific Health-Related Quality of Life (HRQoL). The purpose of this study was to assess the effect of SCIT on alternative disease outcomes in patients with grass-pollen and/or house dust mite induced allergic rhino-conjunctivitis and/or an asthma diagnosis. Focus was on expressing outcomes in terms of generic quality of life (Quality-Adjusted-Life-Years (QALY)) and reductions in sick days.

METHODS

The study was a multi-centre study with prospective follow-up. 248 patients were initiated on SCIT. The disease specific Rhino-conjunctivitis Quality of Life Questionnaire (RQLQ) and two generic (HRQoL) instruments 15D and EQ-5D were used at baseline and at follow-up. The outcome measures included change in; disease severity, RQLQ-scores, number of days with symptoms- and number of sick days per year and finally changes in generic HRQoL and thus, QALY. Disease severity was assessed by specialist doctors; severity of rhino-conjunctivitis was classified according to the Allergic Rhinitis and its Impact on Asthma (ARIA) and asthma severity according to the Global Initiative for Asthma (GINA guideline). The remaining outcome measures were assessed by the patients in questionnaires at baseline and at follow-up. An intension to treat approach was applied. For missing items imputation of sample mean base-line values or follow-up values were used after specified criteria. The effect of SCIT on rhino-conjunctivitis and/or asthma diagnoses was analysed at follow-up using three logistic regression models.

RESULTS

The disease severity showed significantly improved disease control. Mean RQLQ-score was reduced from 3.02 at baseline to 2.00 at follow-up. Average annual days with symptoms were reduced from 189 to 145 days whilst annual sick days were reduced from 3.7 to 1.2 days. The 15D-score increased from 0.83 to 0.86 and the EQ-5D-score from 0.70 to 0.77, which indicated an annual gain per patient of 0.03-0.06 QALY.

CONCLUSIONS

Allergic patients suffering from rhino-conjunctivitis alone or rhino-conjunctivitis and asthma experience significantly increased HRQoL and they gain 0.03-0.06 QALY, when treated with SCIT for one year.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov with the identifier: NCT01486498.

Oral immunotherapy for allergic diseases using transgenic rice seeds: current state and future prospects

Allergen-specific immunotherapy (IT) has been shown to provide clinical benefit for patients with allergic diseases. At present, subcutaneous and sublingual ITs are mainly authorized for clinical treatment. Oral administration of allergens seems to be the easiest way to achieve IT, though it has yet to be translated to the clinical setting, mainly due to the requirement of a large amount of allergens. Plants, especially rice seeds, have recently been recognized as superior allergen carriers for oral administration, because of their high productivity, stability and safety. Therefore, in order to establish clinically applicable oral IT, we have been developing transgenic rice seeds (Tg rice), in which major epitopes of cedar pollen allergens or house-dust mites (HDM) are expressed. The efficacy of this orally administered Tg rice was confirmed in murine models of allergic rhinitis and bronchial asthma. In the safety study of the Tg rice, no adverse effects on cynomolgus macaques were observed. In this review, we summarized the current state and future prospects of allergen-specific IT, focusing particularly on oral IT with allergen-expressing Tg rice.

Assessment of specific immunotherapy efficacy using a novel placebo score-based method

BACKGROUND

In trials of allergen immunotherapy, allergen exposure is typically assessed by pollen counts, but these may misrepresent exposure if performed remotely from multiple study centers.

OBJECTIVE

To assess whether symptomatology in placebo-treated patients is a better measure of local allergen burden at individual centers in such trials.

METHODS

Data from a multicenter, placebo-controlled trial of preseasonal grass pollen immunotherapy were reanalyzed to identify the 4 weeks at each center in which the placebo-treated subjects had the highest combined symptom/medication scores (CSMS). The difference in CSMS between active and placebo groups was compared during the 4 peak placebo score weeks (PlSW) and the 4 peak pollen count weeks (PoCW).

RESULTS

The benefit of immunotherapy over placebo in the PlSW analysis (18.5%) was greater than in the PoCW analysis (13.6%), with increased statistical significance (P = .0001, .0038, respectively). Similar improved discrimination was observed when analyzing benefits in subgroups of patients with severe symptoms, a high disease burden, and in different geographical locations.

CONCLUSION

This novel PlSW analysis results in better discrimination of the effects of allergen immunotherapy compared with placebo and may be widely applicable in similar studies, both prospectively and retrospectively.

Budget impact analysis of two immunotherapy products for treatment of grass pollen-induced allergic rhinoconjunctivitis

BACKGROUND

Grass pollen-induced allergic rhinoconjunctivitis constitutes a large burden for society. Up to 20% of European and United States (US) populations suffer from respiratory allergies, including grass pollen-induced allergic rhinoconjunctivitis. The majority of patients are treated with symptomatic medications; however, a large proportion remains uncontrolled despite use of such treatments. Specific immunotherapy is the only treatment documented to target the underlying cause of the disease, leading to a sustained effect after completion of treatment. The aim of this study was to compare the economic consequences of treating patients suffering from allergic rhinoconjunctivitis with either a grass allergy immunotherapy tablet (AIT) or subcutaneous immunotherapy (SCIT).

METHODS

A budget impact analysis was applied comparing SQ-standardized grass AIT (Grazax(®); Phleum pratense, 75,000 SQ-T/2,800 BAU; ALK, Denmark) with SCIT (Alutard(®); P. pratense, 100,000 SQ-U/mL; ALK, Denmark). Budget impact analysis included health care utilization measured in physical units based on systematic literature reviews, guidelines, and expert opinions, as well as valuation in unit costs based on drug tariffs, physician fees, and wage statistics. Budget impact analysis was conducted from a Danish health care perspective.

RESULTS

Treating patients suffering from allergic rhinoconjunctivitis with grass AIT instead of grass SCIT resulted in a total reduction in treatment costs of €1291 per patient during a treatment course. This cost saving implies that approximately 40% more patients could be treated with grass AIT per year without influencing the cost of treatment.

CONCLUSION

Budget impact analysis showed that grass AIT is a cost-saving alternative to SCIT when treating patients with grass pollen-induced allergic rhinoconjunctivitis.

Managing co-morbid asthma with allergic rhinitis: targeting the one-airway with leukotriene receptor antagonists

Allergic rhinitis is a common inflammatory condition affecting upper airways, nose, and eyes. Allergic rhinitis is a global health problem and is increasing in prevalence. Allergic rhinitis patients have often comorbidities asthma being one of the most common. Up to 40% of patients with allergic rhinitis have asthma and at least as many as 80% of asthma patients experience symptoms of allergic rhinitis. Patients with persistent allergic rhinitis should be evaluated for asthma, and patient with asthma should be properly evaluated for rhinitis. Allergic rhinitis and its impact on asthma update is proposing that treatments for one condition, one airway-one disease, may alleviate the coexisting conditions. Patients need early recognition, proper diagnosis, effective treatment, and follow-up. The treatment should be a combined strategy to treat the upper and lower airways for a good efficacy/safety ratio.

SQ-standardized sublingual grass immunotherapy: confirmation of disease modification 2 years after 3 years of treatment in a randomized trial

BACKGROUND

The main aim of specific immunotherapy is sustained effect due to changes in the immune system that can be demonstrated only in long-term trials.

OBJECTIVE

To investigate sustained efficacy and disease modification in a 5-year double-blind, placebo-controlled trial, including 2 years of blinded follow-up after completion of a 3-year period of treatment, with the SQ-standardized grass allergy immunotherapy tablet, Grazax (Phleum pratense 75,000 SQ-T/2,800 BAU,(∗) ALK, Denmark) or placebo.

METHODS

A randomized, double-blind, placebo-controlled, multinational, phase III trial included adults with a history of moderate-to-severe grass pollen-induced allergic rhinoconjunctivitis, with or without asthma, inadequately controlled by symptomatic medications. Two hundred thirty-eight participants completed the trial. End points included rhinoconjunctivitis symptom and medication scores, combined scores, asthma symptom and medication scores, quality of life, days with severe symptoms, immunologic end points, and safety parameters.

RESULTS

The mean rhinoconjunctivitis daily symptom score was reduced by 25% to 36% (P ≤ .004) in the grass allergy immunotherapy tablet group compared with the placebo group over the 5 grass pollen seasons covered by the trial. The rhinoconjunctivitis DMS was reduced by 20% to 45% (P ≤ .022 for seasons 1-4; P = .114 for season 5), and the weighted rhinoconjunctivitis combined score was reduced by 27% to 41% (P ≤ .003) in favor of active treatment. The percentage of days with severe symptoms during the peak grass pollen exposure was in all seasons lower in the active group than in the placebo group, with relative differences of 49% to 63% (P ≤ .0001). Efficacy was supported by long-lasting significant effects on the allergen-specific antibody response. No safety issues were identified.

CONCLUSION

The results confirm disease modification by SQ-standardized grass allergy immunotherapy tablet in addition to effective symptomatic treatment of allergic rhinoconjunctivitis.

Analysis of allergen immunotherapy studies shows increased clinical efficacy in highly symptomatic patients

BACKGROUND

The assessment of allergen immunotherapy (AIT) efficacy in the treatment for seasonal allergic rhinoconjunctivitis (SAR) symptoms is challenging. Allergen immunotherapy differs from symptomatic therapy in that while symptomatic therapy treats patients after symptoms appear and aims to reduce symptoms, AIT is administered before symptoms are present and aims to prevent them. Thus, clinical studies of AIT can neither establish baseline symptom levels nor limit the enrolment of patients to those with the most severe symptoms. Allergen immunotherapy treatment effects are therefore diluted by patients with low symptoms for a particular pollen season. The objective of this analysis was to assess the effect possible to achieve with AIT in the groups of patients presenting the most severe allergic symptoms.

METHODS

Study centres were grouped into tertiles categorized according to symptom severity scores observed in the placebo patients in each centre (low, middle and high tertiles). The difference observed in the average score in each tertile in active vs placebo-treated patients was assessed. This allowed an estimation of the efficacy that could be achieved in patients from sites where symptoms were high during the pollen season.

RESULTS

An increased treatment effect was observed in the most severe patients and was independent of the study analysed and symptom score used.

CONCLUSIONS

The use of a tertile approach to analyse efficacy in AIT in SAR clinical studies can give a more accurate assessment of potential clinical benefit.

Mucosal exposure to cockroach extract induces allergic sensitization and allergic airway inflammation

Background

Allergic sensitization to aeroallergens develops in response to mucosal exposure to these allergens. Allergic sensitization may lead to the development of asthma, which is characterized by chronic airway inflammation. The objective of this study is to describe in detail a model of mucosal exposure to cockroach allergens in the absence of an exogenous adjuvant.

Methods

Cockroach extract (CE) was administered to mice intranasally (i.n.) daily for 5 days, and 5 days later mice were challenged with CE for 4 consecutive days. A second group received CE i.n. for 3 weeks. Airway hyperresponsiveness (AHR) was assessed 24 h after the last allergen exposure. Allergic airway inflammation was assessed by BAL and lung histology 48 h after the last allergen exposure. Antigen-specific antibodies were assessed in serum. Lungs were excised from mice from measurement of cytokines and chemokines in whole lung lysate.

Results

Mucosal exposure of Balb/c mice to cockroach extract induced airway eosinophilic inflammation, AHR and cockroach-specific IgG1; however, AHR to methacholine was absent in the long term group. Lung histology showed patchy, multicentric damage with inflammatory infiltrates at the airways in both groups. Lungs from mice from the short term group showed increased IL-4, CCL11, CXCL1 and CCL2 protein levels. IL4 and CXCL1 were also increased in the BAL of cockroach-sensitized mice in the short-term protocol.

Conclusions

Mucosal exposure to cockroach extract in the absence of adjuvant induces allergic airway sensitization characterized by AHR, the presence of Th2 cytokines in the lung and eosinophils in the airways.

(Un)Awareness of allergy

Background

Allergy is associated with considerable morbidity.

Objective

The aim of this multicenter study was to provide insight into allergy knowledge and perceptions among the population.

Methods

During the World Allergy Day, several allergy clinics conducted public meetings to encourage the awareness of and education in allergy. At the beginning, participants filled out a questionnaire to assess their knowledge about what is allergy and to determine by whom those symptoms are cared.

Results

A total of 256 participants (187 women/69 men, mean age, 31.2 ± 12.5 years) completed the survey. Of the 202 participants with symptoms, 58.9% had physician-diagnosed allergic disease. Among the 19 symptoms evaluated, 56.5% of the symptoms were recognized as related with allergy, and this increased in compliance with education level (r = +0.427; P < 0.001) but not with diagnosed allergy (P = 0.34). Sneezing was the most common symptom thought to be related with allergy-related symptom (77.5%), whereas loss of smell was the least one (37.9%). Participants were more likely to be cared by an allergologist (72.9%) followed by other specialties, when experiencing allergy.

Conclusions

Increasing the awareness for allergic symptoms is the key not only for the diagnosis but also for the optimal treatment. Therefore, education is an important component of prevention and control of allergic diseases.

Determinants of experimental allergic responses: interactions between allergen dose, sex and age

The prevalence of allergic diseases is influenced by sex and age. Although mouse models are widely used in allergy research, few experimental studies have examined the interaction effects of sex and age on allergy outcomes. Our aim was to investigate the individual and combined effects of sex and age on allergic sensitization and inflammation in two mouse models: an intraperitoneal (i.p.) and an intranasal (i.n.) sensitization model. We also investigated how the allergen immunization dose interacted with age and sex in the i.p. model. Female and male mice were immunized i.p. or i.n. with ovalbumin when 1, 6 or 20 weeks old. In both models, allergen challenges were performed by i.n. delivery. Serum antibodies, draining lymph node cytokine release and airway inflammatory responses were assessed. In the i.p. model, the antibody and cytokine levels and airway inflammation were highly influenced by immunization dose and age. The responses increased with age when using a low immunization dose, but decreased with age when using a high immunization dose. In the i.n. model, antibody production and airway tissue inflammation increased with age. Female compared with male mice generally developed more pronounced antibody and inflammatory responses. Relative to older mice, juvenile mice had augmented airway inflammation to allergen exposures. The study demonstrates that immunization dose, sex and age are highly influential on allergy outcomes. To better mimic different life stages of human allergic airway disease, murine models, therefore, require careful optimization.

Allergy immunotherapy tablet: Grazax® for the treatment of grass pollen allergy

Immunotherapy is the only treatment for allergy that alters the natural course of this disease. Sublingual immunotherapy has been developed to make immunotherapy more suitable for allergic patients. In the largest clinical program ever conducted with grass allergen-specific immunotherapy, over 2000 adults and more than 500 children have been exposed to Grazax(®) (ALK-Abello A/S, Hoersholm, Denmark). Grazax is an oral lyophilisate tablet (allergy immunotherapy tablet [AIT]) for sublingual administration, containing 75,000 standardized quality tablet units of allergen extract of grass pollen (Phleum pratense). Grazax is indicated for treatment of grass pollen-induced rhinitis and conjunctivitis in adult and pediatric patients. Results from the GT-08 trial (first, second and third treatment years) showed a reduction of 31, 36 and 29%, respectively, in symptom scores and a reduction of 38, 45 and 40% of medication scores, respectively, compared with placebo. Subjects treated with Grazax also had an increased number of well days and a relevant improvement in quality of life. More subjects experienced excellent and complete rhinoconjunctivitis control in comparison with patients treated with symptomatic medications only. Grazax treatment is also associated with a sustained and relevant increase of specific IgG4. This increase is also observed after stopping AIT treatment. The most common adverse events related to Grazax treatment are local reactions, such as oral itch, edema of the mouth, ear pruritus, throat irritation and sneezing. Clinical efficacy of Grazax is observed also after 1 and 2 years of follow-up after stopping the AIT treatment. Grazax is efficacious and safe for treatment of grass-pollen rhinoconjunctivitis in both adults and children. Grazax is the first AIT showing a disease-modifying effect on grass pollen-induced allergic rhinoconjuctivitis.

Long-term clinical efficacy in grass pollen-induced rhinoconjunctivitis after treatment with SQ-standardized grass allergy immunotherapy tablet

BACKGROUND

Sustained and disease-modifying effects of sublingual immunotherapy have never before been confirmed in a large-scale randomized, double-blind, placebo-controlled trial.

OBJECTIVE

We sought to investigate sustained efficacy 1 year after a 3-year period of daily treatment with the SQ-standardized grass allergy immunotherapy tablet Grazax (Phleum pratense 75,000 SQ-T/2,800 BAU; ALK-Abelló, Hørsholm, Denmark).

METHODS

A randomized, double-blind, placebo-controlled, phase III trial including adults with a history of moderate-to-severe grass pollen induced rhinoconjunctivitis inadequately controlled by symptomatic medications. The analysis set comprised 257 subjects at the follow-up. Efficacy end points were rhinoconjunctivitis symptom and medication scores, quality of life, and percentages of symptom and medication free days. Immunologic end points included grass pollen-specific serum IgG4 and IgE-blocking factor. Safety was assessed based on adverse events.

RESULTS

Significant improvements in efficacy were consistently shown during 3 years' treatment. One year after treatment, the active group showed sustained reductions in mean rhinoconjunctivitis symptom scores (26%, P < .001) and medication scores (29%, P = .022) when compared with placebo. This level was similar to the efficacy observed during the 3-year treatment period. The differences in percentages of symptom- and medication-free days were significant during and 1 year after treatment. The active group also reported sustained and significant improvements in quality of life. Sustained clinical benefit was accompanied by immunologic changes. No safety issues were identified.

CONCLUSION

Three years of treatment with the SQ-standardized grass allergy immunotherapy tablet resulted in consistent clinical improvement and accompanying immunologic changes that were sustained 1 year after treatment, which is indicative of disease modification and associated long-term benefits.

The Congestion Quantifier Five-Item Test for Nasal Congestion: Refinement of the Congestion Quantifier Seven-Item Test

Background

Patients report that nasal congestion is the most bothersome symptom of allergic rhinitis (AR). Recently, a short, patient-reported congestion screener questionnaire, the Congestion Quantifier Seven-Item Test (CQ7), was developed to identify a level of congestion that may warrant patients seeking evaluation and possible treatment. We explored further item reduction of the CQ7 and examined the psychometric properties of this reduced set of items in a 15-day study of patients with confirmed AR or self-identified and clinician-confirmed congestion.

Methods

The CQ7 was subjected to item reduction methods and the psychometric properties of the reduced set of items were assessed.

Results

Two items were dropped—sinus pressure/pain and impact on work/school—because of lower item-rest correlations. The resulting Congestion Quantifier Five-Item screener (CQ5) performed comparably with the CQ7. Internal consistency reliability of both instruments were identical (alpha = 0.93); test–retest reliability from baseline to day 15 was similar (CQ7, alpha = 0.85; CQ5, alpha = 0.79). Both instruments were comparable in discriminating patients and controls (CQ7, area under the curve [AUC] = 0.97; CQ5, AUC = 0.96). A CQ5 score of 6 provided optimum balance of sensitivity (89.4%), specificity (88.6%), and correct classification (89%) for detecting congestion.

Conclusions

The CQ5, a patient-reported outcome screener, is slightly shorter but equally reliable, valid, and responsive as the CQ7 for evaluating differences in levels of severity of nasal congestion. It may have wider applicability than the CQ7 because of exclusion of the work/school impact item.

Prevalence of childhood allergic diseases in central Taiwan over the past 15 years

BACKGROUND

The prevalence of asthma, allergic rhinitis and atopic eczema in children from the developed and developing countries has been increasing.

METHODS

Three epidemiological surveys of the prevalence of bronchial asthma, allergic rhinitis and atopic eczema in schoolchildren in Taichung, located in central Taiwan, were conducted in 1987, 1994, and 2002. The first questionnaire was used before the International Study of Asthma and Allergies in Childhood (ISAAC) written questionnaire was developed; the last two surveys were modified using ISAAC questionnaires.

RESULTS

A total of 37,801, 75,960, and 11,580 children were studied in 1987, 1994 and 2002, respectively. The prevalence of allergic diseases had increased in the past two decades. Results indicate that the prevalence of bronchial asthma had risen, from 2.19% in 1987, and 3.54% in 1994, to 6.99% in 2002. Regardless of sex, the prevalence of bronchial asthma decreased with increasing age. The prevalence of allergic rhinitis was 5.1% in 1987, 12.46% in 1987, and 27.59% in 2002, and the prevalence of atopic eczema was 1.10% in 1987, 1.88% in 1994, and 3.35% in 2002.

CONCLUSION

There has been a significant increase in the prevalence of bronchial asthma, allergic rhinitis and atopic dermatitis in Taichung schoolchildren from 1987 to 2002.

Treatment of grass pollen allergy: focus on a standardized grass allergen extract - Grazax®

Immunotherapy is the only treatment for allergy that has the potential to alter the natural course of the disease. Sublingual immunotherapy (SLIT) for grass pollen-induced rhino-conjunctivitis has been developed to make immunotherapy available to a broader group of allergic patients. In the largest clinical programme ever conducted with allergen-specific immunotherapy, over 1,700 adults and 260 children have been exposed to Grazax(®). Grazax is formulated as an oral lyophilisate (tablet) for sublingual administration, containing 75,000 SQ-T standardized allergen extract of grass pollen from Phleum pratense. Grazax is indicated for treatment of grass pollen-induced rhinitis and conjunctivitis in adult patients with clinically relevant symptoms and diagnosed with a positive skin prick test and/or specific IgE test to grass pollen. In phase I trials doses from 2,500 to 1,000,000 SQ-T were tested. All doses were well tolerated and 75,000 SQ-T, with approximately 15 mug major allergen protein, was chosen as the optimal dose. Three phase III trials are ongoing, one being a long-term trial. Results from GT-08 trial first and second treatment years showed a reduction of 30% and 36%, respectively, in daily rhino-conjunctivitis symptom scores and a reduction of 38% and 46% of daily rhino-conjunctivitis medication scores compared with placebo over the entire grass pollen season. Subjects treated with Grazax also had an increased number of well days and improved quality of life, and more subjects experienced excellent rhino-conjunctivitis control. The most common adverse events related to Grazax are local reactions, such as pruritus, edema mouth, ear pruritus, throat irritation, and sneezing. We conclude that Grazax is efficacious and safe for treatment of rhino-conjunctivitis due to grass pollen allergy.

Primary care: the cornerstone of diagnosis of allergic rhinitis

Allergic rhinitis (AR) is a very common disease with over 600 million people (200 million of them with concomitant asthma) worldwide suffering from it. The majority of patients who seek medical advice are seen in primary care. Although there is a selection of guidelines focused on the management of AR, there is a paucity of guidance on how best to identify patients who would most benefit from treatment. The aim of this paper was to review the best practice for primary care with respect to the diagnosis of AR within that clinical environment.

Effect of grass pollen immunotherapy with Alutard SQ on quality of life in seasonal allergic rhinoconjunctivitis

BACKGROUND

Treatment of allergic rhinitis with subcutaneous allergen immunotherapy is effective in terms of reductions in symptoms and seasonal use of reliever medication. Its effect on quality of life (QoL), reflecting the impact of symptoms on work/school performance and leisure activities is, however, important and often overlooked.

AIMS OF THE STUDY

To assess effect on QoL of specific immunotherapy with two doses of Alutard SQ Phleum pratense in patients with moderately to severe seasonal allergic rhinoconjunctivitis inadequately controlled by standard drug therapy.

METHODS

Double-blind, randomized, placebo-controlled study of 410 patients with seasonal allergic rhinoconjunctivitis. Participants were randomized (2 : 1 : 1) to receive Alutard SQ P. pratense (ALK-Abelló) at maintenance doses of 100,000 SQ-U (203 subjects), 10,000 SQ-U (104 subjects) or placebo (103 subjects) given by subcutaneous injections. The groups were well matched for demographics and baseline symptoms. Quality of life was assessed using the Rhinoconjunctivitis Quality of Life Questionnaire which covers seven domains of health before and in the peak of the pollen season.

RESULTS

While all domain scores were significantly improved when comparing 100,000 SQ-U with placebo, two domain scores were significantly improved when comparing 10,000 SQ-U with placebo. When comparing 100,000 SQ-U with 10,000 SQ-U, four domain scores were significantly improved.

CONCLUSION

Treatment with Alutard SQ significantly improved the seasonal QoL of patients suffering from allergic rhinoconjunctivitis. The improvement was more pronounced and wider ranging in patients who received the higher 100,000 SQ-U maintenance dose.

Development and validation of the Congestion Quantifier seven-item test (CQ7): a screening tool for nasal congestion

OBJECTIVE

This study aimed to develop and validate a short, simple, patient-completed instrument for identifying patients with congestion in a 15-day study. Allergic rhinitis (AR) is the most common allergic condition worldwide, with congestion as one of the most salient symptoms. Nevertheless, there is no short screening tool designed specifically to identify congestion that can help patients make decisions about seeking treatment.

METHODS

Patients (N = 354) received a clinical exam to confirm congestion and assess its possible causes including confirmation of AR. They completed the 13-item draft of the Congestion Quantifier (CQ) and five additional patient-reported outcome instruments.

RESULTS

The 13-item draft CQ was reduced to a seven-item version, the CQ7. Internal consistency reliability was 0.93; test-retest reliability = 0.85. Construct validity was demonstrated by significant correlations with the Medical Outcomes Study Sleep Scale, the Work Productivity and Activity Impairment Questionnaire-Allergy Specific, and the Positive Affect and Negative Affect Scale Fatigue subscale (r = 0.23-0.67). The CQ7 can discriminate between controls and patients (AUC > 0.9). Moreover, it can discriminate between different levels of severity of symptoms of AR. A score of 7 provided optimum balance of sensitivity (91%), specificity (86%), and correct classification (90%) for detecting congestion.

CONCLUSION

The CQ7 is reliable, valid, and responsive to differences in severity of nasal congestion. The CQ7 can identify patients with congestion that may need to be evaluated by a clinician.

Safety of specific sublingual immunotherapy with SQ standardized grass allergen tablets in children

The aim of the study was to confirm the safety of an orodispersible grass allergen tablet 75,000 SQ-T (Grazax, ALK-Abelló A/S, Hørsholm, Denmark) in children aged 5-12 yr. The study was randomized, double-blinded and placebo-controlled. Sixty children aged 5-12 yr suffering from grass pollen-induced rhinoconjunctivitis (with or without asthma) from five centres in two countries (three in Germany and two in Spain) participated in the study. They were randomized at the ratio of 3:1 as receiving either Grazax or placebo tablet given sublingually once daily for 28 days outside the grass pollen season. A total of 810 treatment-related adverse events were reported in the Grazax group. The majority of these were local reactions in the mouth or throat and were mostly mild (71%) to moderate (27%) in severity and resolved within days. Thirty-five (78%) subjects treated with Grazax and five (33%) treated with placebo reported at least one treatment-related adverse event. Oral pruritus, throat irritation, mouth oedema and ear pruritus appeared as the most frequently reported treatment-related adverse events. 62% (28 of 45) of the actively treated subjects reported oral pruritus, 36% (16 of 45) throat irritation, 31% (14 of 45) mouth oedema and 22% (10 of 45) ear pruritus. Two actively treated subjects withdrew from the study: one subject due to four adverse events (moderate eye pruritus, moderate pharyngolaryngeal pain, moderate non-cardiac chest pain and moderate dysphagia) and one subject due to a serious adverse event (asthmatic attack). The subjects recovered completely from the events. In conclusion, in the present study, Grazax was in general tolerated in a paediatric population and considered suitable for further clinical investigations in children.

Asthma out of control? A structured review of recent patient surveys

BACKGROUND

An understanding of the needs and behaviors of asthma patients is important in developing an asthma-related healthcare policy. The primary goal of the present review was to assess patient perspectives on key issues in asthma and its management, as captured in patient surveys.

METHODS

Local, national, and multinational asthma surveys were reviewed to assess patient perspectives, and where possible healthcare provider (HCP) perspectives, on key issues, including diagnosis, treatment, control, quality of life, and other patient-centered outcomes. Twenty-four surveys, conducted or published between 1997 and 2003 in Europe and North America, were included in this review. Substantial differences among studies prevented a formal meta-analysis; instead, data were pooled to allow for general comparisons and qualitative analysis.

RESULTS

The results indicate that patients' knowledge of the underlying causes of asthma and treatment options remains inadequate. Moreover, patients often tolerate poor symptom control, possess meager knowledge of correct drug usage, and display insufficient adherence to therapy. Many patients have a low expectation of receiving an appropriate therapy or of having a positive encounter with the HCP. Among HCPs, there is evidence of inadequate understanding of disease etiology and poor or unstructured communication with patients, resulting often in inaccurate assessment of disease severity. Moreover, patients often underreport their symptoms and severity, which in turn could lead to misclassification and undertreatment.

CONCLUSION

Improving patient education about the importance of achieving optimal asthma control, along with improved communication between patients and HCPs, emphasizing treatment options and optimal treatment of inflammation, may lead to better outcomes and improved asthma management in daily practice.

Once-daily sublingual allergen-specific immunotherapy improves quality of life in patients with grass pollen-induced allergic rhinoconjunctivitis: a double-blind, randomised study

The effect of sublingual immunotherapy on quality of life (QoL) was examined in patients with grass pollen-induced rhinoconjunctivitis. Patients (n = 855) were randomised to once-daily grass allergen tablets (2,500; 25,000; or 75,000 SQ-T Phleum pratense extract; GRAZAX or placebo. Treatment was initiated 8 weeks before the start of the grass pollen season and continued throughout. If symptoms were present, patients received loratadine or placebo rescue medication. There were three major findings: in patients using loratadine, grass allergen tablets provided QOL benefits over placebo; Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) score was 17% (p = 0.006) and 20% (p = 0.020) greater with 75,000 SQ-T tablet than with placebo at first and second seasonal visit, respectively; in patients not using loratadine, grass allergen tablets improved QoL more than placebo; RQLQ score was 21% greater (p = 0.021) with 75,000 SQ-T tablet at second seasonal visit; grass tablets (without loratadine) had a greater effect on QoL than loratadine alone. RQLQ score was 26% (p = 0.014) greater with 75,000 SQ-T tablets than loratadine at second seasonal visit. These data show that sublingual immunotherapy with grass allergen tablets improves QOL in allergic rhinoconjunctivitis, reduces symptoms, and that this effect is greater than rescue antihistamine alone.

An exploratory retrospective study of people suffering from hypersensitivity illnesses who attend medical or classical homeopathic treatment

The objective of this study is to describe patients who had treatment for hypersensitivity illnesses by general practitioners (GPs) or classical homeopaths (CHs) and the patients' self-reported effectiveness of the treatment received. The data stems from an exploratory retrospective study amongst 88 Danish patients (response rate 58%) suffering from hypersensitivity illnesses, who chose treatment from one of six GPs or one of 10 CHs who participated in the project. The patients themselves selected their treatment. The GPs or the CHs considered that the patient's treatment was complete or that the patient was in a situation of current 'maintenance treatment'. The patients' primary reason for consulting the GP or the CH was that they were suffering from hypersensitivity illnesses. No significant difference was found between the two groups of patients in relation to age, education and duration of hypersensitivity symptoms. The CH patients were more likely to be employed in teaching, research, health care or the social sector compared to GP patients. The two groups of patients were similar in respect of their health at the start of the treatment, 57% of the patients who consulted a CH experienced an improvement of their state of health compared to 24% of the GP patients. Both groups of patients experienced an improvement of their psychological health after treatment. Logistic regression analysis showed that the GP or CH was the only significant effect variable. The results are based on the patients' retrospective, self-reported effectiveness of the treatments.