The link between the nose and lung, perennial rhinitis and asthma--is it the same disease?

Intranasal levels of lead as an exacerbation factor for allergic rhinitis in humans and mice

BACKGROUND

Air pollutants are suspected to affect pathological conditions of allergic rhinitis (AR).

OBJECTIVES

After detecting Pb (375 μg/kg) in Japanese cedar pollen, the effects of intranasal exposure to Pb on symptoms of AR were investigated.

METHODS

Pollen counts, subjective symptoms, and Pb levels in nasal epithelial lining fluid (ELF) were investigated in 44 patients with Japanese cedar pollinosis and 57 controls from preseason to season. Effects of intranasal exposure to Pb on symptoms were confirmed by using a mouse model of AR.

RESULTS

Pb levels in ELF from patients were >40% higher than those in ELF from control subjects during the pollen season but not before the pollen season. Pb level in ELF was positively associated with pollen counts for the latest 4 days before visiting a hospital as well as scores of subjective symptoms. Intranasal exposure to Pb exacerbated symptoms in allergic mice, suggesting Pb as an exacerbation factor. Pb levels in ELF and nasal mucosa in Pb-exposed allergic mice were higher than those in Pb-exposed nonallergic mice, despite intranasally challenging the same amount of Pb. Because the increased Pb level in the nasal mucosa of Pb-exposed allergic mice was decreased after washing the nasal cavity, Pb on the surface of but not inside the nasal mucosa may have been a source of increased Pb level in ELF of allergic mice.

CONCLUSIONS

Increased nasal Pb level partially derived from pollen could exacerbate subjective symptoms of AR, indicating Pb as a novel hazardous air pollutant for AR.

Expression of proteins associated with airway fibrosis differs between children with allergic asthma and allergic rhinitis

Allergic rhinitis (AR) and allergic asthma (AA) exhibit similar inflammatory response in the airways. However, the remodelling is more extensive in the lower airways, suggesting that the inflammation itself is not sufficient for allergic phenotype. We aimed to analyse whether the expression of selected 27 inflammatory and fibrosis-related proteins may be altered in AR and AA in the paediatric population and whether the expression pattern is either similar (due to the inflammation) or disease-specific (due to the remodelling). We analysed 80 paediatric subjects: 39 with AA, 21 with AR and 20 healthy children. The diagnosis of AR and AA was based on clinical manifestation, lung function, positive skin prick tests and increased immunoglobulin E levels. Serum levels of selected inflammatory proteins were measured with custom Magnetic Luminex Assay. Statistical analysis was performed in Statistica v.13. CCL2/MCP1, GM-CSF, gp130 and periostin concentrations were significantly lower, whereas IL-5 levels were higher in AA compared to the control group. CD-40L, CHI3L1/YKL-40, EGF, GM-CSF and periostin levels were significantly decreased in patients with AR than in the control group. Comparison of AA and AR patients revealed significant changes in CHI3L1/YKL-40 (P = 0.021), IL-5 (P = 0.036), periostin (P = 0.013) and VEGFα (P = 0.046). Significantly altered proteins were good predictors to distinguish between AA and AR (P < 0.001, OR 46.00, accuracy 88.57%). Our results suggest that the expression of four fibrotic proteins was significantly altered between AA and AR, suggesting possible differences in airway remodelling between upper and lower airways.

Assessment of Pulmonary Function before and after Sinus Surgery in Lung Transplant Recipients

Introduction  The association between sinus and lung diseases is well known. However, there are scarce studies regarding the effects of sinus surgery on pulmonary function in lung transplant recipients. The present study describes our experience with sinus surgery in lung transplant recipients with chronic rhinosinusitis. Objectives  To assess the impact of sinus surgery for chronic rhinosinusitis on pulmonary function and on inpatient hospitalization days due to lower respiratory tract infection in lung transplant recipients. Methods  A retrospective study conducted between 2006 and 2012 on a sample of lung transplant recipients undergoing sinus surgery for chronic rhinosinusitis. Pulmonary function, measured by forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1), as well as inpatient hospitalization days due to lower respiratory tract infection, were compared 6 months before and 6 months after sinus surgery. Results  The FEV1 values increased significantly, and the inpatient hospitalization days due to bronchopneumonia decreased significantly 6 months after sinus surgery. The preoperative and postoperative median FEV1 values were 2.35 and 2.68 respectively ( p  =  0.0056 ). The median number of inpatient hospitalization days due to bronchopneumonia 6 months before and 6 months after surgery were 32.82 and 5.41 respectively ( p  =  0.0013 ). Conclusion  In this sample of lung transplant recipients with chronic rhinosinusitis, sinus surgery led to an improvement in pulmonary function and a decrease in inpatient hospitalization days due to bronchopneumonia.

Genetic risk of TNFSF4 and FAM167A-BLK polymorphisms in children with asthma and allergic rhinitis in a Han Chinese population

BACKGROUND

Asthma and allergic rhinitis (AR) frequently occur as comorbid diseases of the upper airways. Single-nucleotide polymorphisms (SNPs) in the TNFSF4 and FAM167A-BLK genes have recently been shown to be associated with various immune-related disorders.

OBJECTIVE

Our aim was to determine whether TNFSF4 or FAM167A-BLK polymorphisms confer genetic susceptibility to asthma and AR in a Han Chinese population.

METHODS

We performed a case-control study of 290 asthmatic children and 252 healthy controls. Nine SNPs in the TNFSF4 region (rs1234313, rs1234314, rs1234315, rsl 2039904, rs844648 and rsl 0912580) and the FAM167A-BLK region (rs2254546, rs13277113 and rs1600249) were detected using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay.

RESULTS

This study revealed that three SNPs in TNFSF4 (rsl 234313, rsl 234314 and rsl 234315) and two SNPs in FAM167A-BLK (rs2254546 and rsl 600249) were significantly correlated with asthma and AR, while SNP rsl600249 was associated with asthma without allergic rhinitis as a risk factor. Further, we demonstrated synergistic effects between the TNFSF4 and FAM167A-BLK SNPs.

CONCLUSION

This study supports that the SNPs in TNFSF4 and FAM167A-BLK may be involved in asthma and AR gene risk in the Han Chinese cohort.

Aggravation of airway inflammation and hyper-responsiveness following nasal challenge with Dermatophagoides pteronyssinus in perennial allergic rhinitis without symptoms of asthma

BACKGROUND

House dust mites are the most prevalent allergen causing sensitizations in patients with rhinitis and asthma in China. We aimed to investigate the changes in both upper and lower airway inflammation and responsiveness following Dermatophagoides pteronyssinus (Der-p) nasal provocation test (NPT) in rhinitis patients.

METHODS

Study subjects included 15 nonasthmatic Der-p-sensitized rhinitis (AR) patients with airway hyper-responsiveness (AHR) (AR+AHR+), 15 AR patients without AHR (AR+AHR-), 15 healthy controls (HCs) with Der-p sensitization (HC+DP+), and 15 HC without Der-p sensitization (HC+DP-). All subjects underwent Der-p NPT. Visual analogue scale (VAS) scores of nasal symptoms, nasal lavage and nasal airway resistance (NAR) measurement, sputum induction, and forced expiratory volume in 1 second (FEV1 ) were performed. Airway responsiveness to histamine bronchoprovocation (PD20 -FEV1 ) and exhaled nitric oxide (FeNO) was determined.

RESULTS

NAR increased significantly in all subjects with the greatest effect seen in AR+AHR+ individuals. VAS increased in all subjects at 30 min and returned to baseline at 6 h, with significantly higher levels in AR+AHR+ and AR+AHR- subjects (P < 0.05). Eosinophils in nasal lavage fluid and sputum increased significantly after NPT in AR+AHR+ and AR+AHR- subjects (P < 0.001). FEV1 % and PD20 -FEV1 decreased and FeNO increased significantly after NPT only in AR+AHR+ subjects (P < 0.05). Nasal lavage eosinophil count was positively correlated with sputum eosinophil count and the level of FeNO and negatively correlated with FEV1 and PD20 .

CONCLUSIONS

House dust mite nasal provocation test induces and aggravates both upper and lower airway inflammation and hyper-responsiveness in patients with persistent allergic rhinitis without asthmatic symptoms.

Allergic Respiratory Inflammation and Remodeling

Asthma and rhinitis are inflammatory diseases of the respiratory tract. Respiratory inflammation of the adaptive and innate immune system is the focus of this review, and chronic inflammation is not limited to the respiratory tissue. The inflammatory response, which consists of phagocytes, eosinophils, mast cells, and lymphocytes, spreads along the respiratory tract, leading to tissue damage. Mast cells and eosinophils are commonly recognized for their detrimental role in allergic reactions on activation through the high- and low-affinity receptors for IgE FcɛRI. These cells rapidly produce and secrete many of the mediators responsible for the typical symptoms of asthma and rhinitis. However, increasing amount of evidence demonstrate that mast cells and leukocytes have vital roles in host defense against pathogenesis. Histological methods are used to study leukocytes and receptor expression pattern in different respiratory tract compartments. The overall aim of this review was to understand the relationship between upper and lower respiratory tract inflammation and remodeling in patients with allergic and non-allergic asthma and rhinitis. In conclusion, this review discusses the relationship between the upper and lower airway in respiratory disease and focuses on the effect of respiratory processes on laryngeal inflammation, remodeling, function, and symptoms; however, they also have a central role in the initiation of the allergic immune response. Our findings suggest that there are differences that contribute to the development of immunopathological mechanisms of these clinically distinct forms of asthma, rhinitis, and chronic obstructive pulmonary disease.

A milestone in house dust-mite-allergen immunotherapy: the new sublingual tablet S-524101 (actair)

Subcutaneous allergen-specific immunotherapy has long been used in the treatment of allergic rhinitis and/or asthma and its efficacy has been confirmed. However, due to the discomfort of injections and the risk of severe adverse reactions, alternative routes of allergen administration have emerged. Delivery of allergens through the mucosal route had been proposed and investigated thoroughly, confirming the sublingual route to be the most efficacious. Later, the efficacy and safety of this route have been documented by numerous controlled trials both for house dust mite (HDM) and pollens. Recently, sublingual orodispersable grass pollen allergen tablets were in use followed by the newly developed HDM allergen tablets with satisfactory clinical results: Moreover, very recently 1 year of HDM tablet treatment was demonstrated to exert its clinical efficacy 1 year after discontinuation of tablet IT. The persistence of efficacy after only 1 year of treatment is a new and promising era. Currently, Sublingual Immunotherapy is the most easily administered and safe treatment option until more immunogenic, less allergenic and more efficient allergen extracts are developed.

Efficacy and safety of sublingual tablets of house dust mite allergen extracts in adults with allergic rhinitis

BACKGROUND

Preliminary studies have suggested the efficacy of sublingual tablets of house dust mite (HDM) extracts in adults with allergic rhinitis.

OBJECTIVES

We sought to assess the efficacy and safety of 2 doses of HDM sublingual tablets over 1 treatment year and the subsequent immunotherapy-free year.

METHODS

Adults with HDM-associated allergic rhinitis were randomized in a double-blind, placebo-controlled study to receive 500 index of reactivity (IR) tablets, 300IR tablets, or placebo administered once daily for 1 year and were followed for the subsequent year. The primary efficacy variable was the Average Adjusted Symptom Score over the year 1 primary period (ie, October 1 to December 31). Symptoms and rescue medication scores, onset of action, patient-reported outcomes, and safety were secondary variables. The same end points were evaluated during the immunotherapy-free year. The primary efficacy end point was analyzed by using analysis of covariance.

RESULTS

Five hundred nine participants were randomized, and 427 continued in the immunotherapy-free year. Both the 500IR and 300IR HDM sublingual tablets significantly reduced mean Average Adjusted Symptom Scores compared with placebo by -20.2% (P = .0066) and -17.9% (P = .0150), respectively. Efficacy of both doses was maintained during the treatment-free follow-up phase. The onset of action was at 4 months. Participants' global evaluation of treatment success was significantly higher in the 500IR and 300IR groups compared with the placebo group (P = .0206 and P = .0001, respectively). Adverse events were generally application-site reactions. There were no reports of anaphylaxis.

CONCLUSIONS

Twelve months of treatment with 500IR and 300IR sublingual tablets of HDM allergen extracts was efficacious and well tolerated. Efficacy was maintained during the treatment-free follow-up year.

Poor asthma control?--then look up the nose. The importance of co-morbid rhinitis in patients with asthma

Many factors can impair asthma control. One which is frequently overlooked is rhinitis. Asthma patients with significant rhinitis are over four times more likely to have poorly controlled asthma than those without. Over 80% of patients with asthma have rhinitis, which may be allergic or inflammatory/non-allergic. Both types of rhinitis share pathophysiological similarities with eosinophilic asthma, cause bronchial hyper-reactivity, and are predisposing factors for the subsequent development of asthma. Nasal allergen challenge in allergic rhinitis results in inflammation in the bronchi as well as the nose, and the reverse is also true. This article reviews briefly the evidence for the link between asthma and rhinitis, advocates looking for rhinitis when patients present with poorly controlled asthma, and provides guidance for the diagnosis and treatment of rhinitis.

Nasal eosinophilia can predict bronchial hyperresponsiveness in persistent rhinitis: evidence for united airways disease concept

BACKGROUND

Nasal eosinophils may be indicative of bronchial hyperresponsiveness (BHR) in rhinitis concerning the "united airways disease" theory. This study was designed to evaluate the relationship between nasal eosinophilia and BHR in persistent perennial rhinitis patients.

METHODS

Thirty-seven patients (12 males and 25 females, mean age: 33.3 ± 10.4 years) were included in the study. Skin-prick test, nasal symptom score, nasal smears, methacholine bronchial challenge test, and nasal rhinometry were obtained in all patients. Eosinophil count in nasal smears was expressed as a percentage of the total cells. None of the patients had asthma.

RESULTS

There was no difference between the number of atopic and nonatopic patients having BHR (4/20 versus 4/17; chi-squared = 0.07; p > 0.05). Total nasal flow was lower and percentage of nasal eosinophils was higher in the patients with BHR than in patients without BHR (p = 0.012 and p = 0.009, respectively). A cutoff point of 68% nasal eosinophils yielded a sensitivity of 100% (63.1-100) and a specificity of 58.6% (38.9-76.5) to determine the presence of BHR. Positive likelihood ratio for the value of eosinophils above cutoff value was 2.42 (1.8-3.3).

CONCLUSION

This study shows the relationship between nasal eosinophils and BHR in persistent perennial rhinitis patients. Nasal eosinophil percentage below cutoff value indicates that a patient does not have BHR.

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

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

Comparative responses to nasal allergen challenge in allergic rhinitic subjects with or without asthma

BACKGROUND

Nasal allergen challenge (NAC) is useful to study the pathophysiology of rhinitis, and multiple challenges may more adequately approximate natural exposure.

OBJECTIVE

To determine the effect of 4 consecutive daily NAC, on clinical and inflammatory parameters in rhinitics with or without asthma.

METHODS

Rhinitic subjects were recruited: 19 with mild asthma and 13 without asthma. Subjects underwent a control challenge (normal saline) followed by 4 consecutive daily NAC. Allergen challenge consisted of spraying the chosen allergen extract into each nostril until a positive nasal response occurred. Symptoms were recorded on a Likert scale, and oral peak expiratory and nasal peak inspiratory flows allowed assessment of a nasal blockage index (NBI), for a period of 7 hours. Induced sputum and nasal lavage were performed on control day and after 1 and 4 days of NAC.

RESULTS

Compared with the control day, there was a significant increase in symptom scores and NBI 10 minutes after each last daily NAC in both groups (p < 0.05). Symptom scores and NBI were similar for the 2 groups, except for nasal obstruction and rhinorrhea, which were more marked in subjects with asthma and rhinitis, respectively. Nasal lavage eosinophils were increased after 4 days of challenges in both groups, but there was no change in sputum eosinophils. No cumulative effect or any late response were observed in any of the groups over the challenge period.

CONCLUSION

Multiple NAC may be a useful tool to study the pathophysiology of allergic rhinitis or its relationships with asthma.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01286129.

Bidirectional link between upper and lower airways in patients with allergic rhinitis

OBJECTIVE

Exhaled nitric oxide has been proposed as a noninvasive marker of eosinophilic airway inflammation in lower airways. The aim of the study was to investigate the impact of atopy, pollen exposure, and pharmacological treatment on NO production in lower airways of patients with allergic rhinitis.

SUBJECTS AND METHODS

Measurements of exhaled NO were performed in 79 non-asthmatic subjects with seasonal allergic rhinitis outside and in pollen season, before and after pharmacological treatment, and in 54 healthy controls.

RESULTS

Patients with allergic rhinitis had significantly higher levels of exhaled NO (18.3 +/-11.0 ppb) than healthy controls (13.0 +/-7.2 ppb) measured outside the pollen season (P=;0.0024). Increased exhaled NO levels were also found in patients with allergic rhinitis in the pollen season (27.0 +/-20.0 ppb) compared with the levels outside pollen season (P=0.0001), before pharmacological treatment. In rhinitic patients treated by nasal corticosteroids and antihistamines in the pollen season, the levels of exhaled NO were significantly lower (17.0 +/-16.4 ppb; P=0.045) than those before treatment. No difference was found in NO levels in rhinitic patients outside and in pollen season after pharmacological treatment.

CONCLUSIONS

This study has shown the presence of eosinophilic airway inflammation in the lower airways in allergic rhinitis patients. A significant increase of exhaled NO after pollen exposure in rhinitic patients underlies the impact of inflammation on the upper respiratory tract. A bidirectional link between upper and lower airways is confirmed by a decrease in exhaled NO in the pollen season, almost to the starting levels, after application of topic corticosteroids and antihistamines.

Community pharmacy provision of allergic rhinitis treatments: a longitudinal study of patient reported outcome

Objective

To monitor and compare the symptoms, and reported quality of life, of two groups of people who obtained treatment for allergic rhinitis from community pharmacies (prescribed or purchased).

Method

Subjects were recruited by 64 community pharmacies in 2001 and followed up by postal questionnaire at four time points: five days, four weeks, eight weeks and 26 weeks. Setting Primary care: community pharmacies in Grampian, Scotland.

Results

Response rates: five days — 84%; four weeks — 63%; eight weeks — 59%; 26 weeks — 56%. Three hundred and twenty-four subjects completed the five-day questionnaire (138 prescribed, 186 purchased). There were no important differences between groups in socio-economic variables monitored. The commonest treatments provided were antihistamines (non-sedating: 63% prescribed, 59% purchased; sedating: 3% prescribed, 16% purchased). Despite treatment, symptoms and quality-of-life impairments remained high; the prescribed group reported higher levels of many symptoms (including asthma), and lower quality of life at early time points. Most were satisfied with their treatment and few reported unmet need for pharmacy advice (11% prescribed, 3% purchased group).

Conclusion

Despite high levels of patient satisfaction with allergic rhinitis treatment, symptoms and quality-of-life impairments remained high in both groups. Widespread implementation of ‘allergic rhinitis and its impact on asthma’ (ARIA) guidelines for physicians and for pharmacists might improve management of symptoms and quality of life of patients.

Important research questions in allergy and related diseases: 3-chronic rhinosinusitis and nasal polyposis - a GALEN study

Chronic rhinosinusitis is one of the most common health care challenges, with significant direct medical costs and severe impact on lower airway disease and general health outcomes. The diagnosis of chronic rhinosinusitis (CRS) currently is based on clinical signs, nasal endoscopy and CT scanning, and therapeutic recommendations are focussing on 2 classes of drugs, corticosteroids and antibiotics. A better understanding of the pathogenesis and the factors amplifying mucosal inflammation therefore seems to be crucial for the development of new diagnostic and therapeutic tools. In an effort to extend knowledge in this area, the WP 2.7.2 of the GA(2)LEN network of excellence currently collects data and samples of 1000 CRS patients and 250 control subjects. The main objective of this project is to characterize patients with upper airway disease on the basis of clinical parameters, infectious agents, inflammatory mechanisms and remodeling processes. This collaborative research will result in better knowledge on patient phenotypes, pathomechanisms, and subtypes in chronic rhinosinusitis. This review summarizes the state of the art on chronic rhinosinusitis and nasal polyposis in different aspects of the disease. It defines potential gaps in the current research, and points to future research perspectives and targets.

Expression of uteroglobin in a murine model of allergic rhinitis

CONCLUSION

We observed for the first time the expression of Uteroglobin (UGB) in the nasal mucosa of mice. The results of our study suggest that UGB may play an important role in the regulation of inflammation in allergic rhinitis (AR) as well as in the lower airway allergic inflammations.

OBJECTIVES

Uteroglobin is a protein secreted by epithelial lining of organs communicating with the external environment. Reports of its immunomodulatory effects in allergic disease have been made, but the true physiological role still remains to be elucidated. In this study we tried to observe the expression of UGB in the nasal mucosa of mice and determine its role in AR.

MATERIALS AND METHODS

Thirty BALB-c mice at 3 weeks of age (10 mice/group) were sensitized systemically by intraperitoneal ovalbumin injection and locally by ovalbumin inhalation. Control group were sensitized with PBS. Treatment group had intraperitoneal dexamethasone injection 1 hour before the initial sensitization while control and AR group were injected with PBS. Symptom scores, eosinophil counts, immunohistochemical staining as well as UGB mRNA expression in the nasal mucosa and lung tissue were analyzed.

RESULTS

The symptom scores and eosinophil counts between control and treatment group was significantly different from the AR group (P<0.01). On immunohistochemical staining, UGB was localized in the epithelium and submucosal gland of the nasal mucosa as well as in the epithelium of respiratory bronchioles. UGB mRNA expression of the nasal mucosa and lung tissue was decreased in the AR group compared to the control group (P=0.022). In the treatment group UGB expression was increased compared to the AR group (P=0.016). The results of IHC and mRNA expression in the lung tissue correlated with the results in the nasal mucosa.

[Allergic inflammatory diseases of the upper airways and their impact on asthma--following on from a case report]

The authors present a case report of a patient referred to physician for "difficult-to-treat asthma". Clinical evaluation concluded that severe chronic inflammatory upper airway disease was an asthma worsening factor. Patient demonstrated improvement in asthma control, after surgery. In the context of the clinical study, the authors present a review of the most common allergic inflammatory diseases of the upper airways (allergic rhinitis, chronic sinusitis and nasal polyposis) and reflect on their impact on asthma.

An assessment of sinus quality of life and pulmonary function in children with cystic fibrosis

BACKGROUND

Treatment of patents with cystic fibrosis (CF) is primarily directed at the lungs. However, there is a growing feeling that the status of the sinuses may have a profound influence on the status of the lungs in these patients. A number of investigators have demonstrated a relationship among coexisting rhinitis, sinusitis, other upper airway conditions, and lung disease. Several studies have shown that treatment and resolution of sinusitis results in an improvement in a number of pulmonary conditions. We hypothesize that pulmonary function test scores will be lower in patients with CF with more severe sinusitis.

METHODS

Consecutive CF patients were asked to complete a sinus-specific quality-of-life instrument, the 16-item Sino-Nasal Outcome Test (SNOT-16), and these scores, were compared to FEV, scores.

RESULTS

Univariate analysis revealed a significant correlation between SNOT-16 and FEV1 in patients under the age of 12. There was a trend toward significance in the older children and evaluation of the raw data shows that children with the highest FEV, had the lowest SNOT-16.

CONCLUSION

This study indicates that the severity of sinus disease correlates with the severity of pulmonary disease in CF patients under the age of 12. We plan to use the SNOT-16 to assess sinus interventions on pulmonary status.

Induction of airway remodeling of nasal mucosa by repetitive allergen challenge in a murine model of allergic rhinitis

BACKGROUND

Although many studies regarding airway remodeling in asthma have been reported, only a few studies have investigated airway remodeling in allergic rhinitis.

OBJECTIVES

To determine whether repetitive allergen challenge could induce airway remodeling in the nose and evaluate the effect of steroids using a murine model of allergic rhinitis.

METHODS

To develop a mouse model of airway remodeling, ovalbumin-sensitized mice were repeatedly exposed to inhaled ovalbumin administration twice a week for 1 month and 3 months. Matched control mice were challenged with phosphate-buffered saline, and the treatment group received intraperitoneal dexamethasone injection. Trichrome, periodic acid-Schiff, hematoxylin-eosin, and immunohistochemical staining against matrix metalloproteinase 9 and tissue inhibitors of metalloproteinase 1 were performed to nasal and lung tissues, and the level of transforming growth factor beta in the nasal lavage fluid was analyzed.

RESULTS

Repetitive ovalbumin challenge for 3 months induced circumferential peribronchial fibrosis in the lung. In the nose, subepithelial fibrosis, increased matrix metalloproteinase 9 and tissue inhibitors of metalloproteinase 1 expression, goblet cell hyperplasia, and submucous gland hypertrophy were observed compared with the control group. Features of airway remodeling were more prominent in the lung tissue. Administration of dexamethasone significantly inhibited these histologic changes.

CONCLUSION

Airway remodeling associated with long-term allergen challenge can occur in the nasal mucosa and the lung. Steroid treatment prevents airway inflammation in response to acute allergen challenge, as well as airway remodeling by long-term allergen challenge.

Intranasal and inhaled fluticasone propionate for pollen-induced rhinitis and asthma

BACKGROUND

Studies suggest that nasal treatment might influence lower airway symptoms and function in patients with comorbid rhinitis and asthma. We investigated the effect of intranasal, inhaled corticosteroid or the combination of both in patients with both pollen-induced rhinitis and asthma.

METHODS

A total of 262 patients were randomized to 6 weeks' treatment with intranasal fluticasone propionate (INFP) 200 microg o.d., inhaled fluticasone propionate (IHFP) 250 microg b.i.d., their combination, or intranasal or inhaled placebo, in a multicentre, double-blind, parallel-group study. Treatment was started 2 weeks prior to the pollen season and patients recorded their nasal and bronchial symptoms twice daily. Before and after 4 and 6 weeks' treatment, the patients were assessed for lung function, methacholine responsiveness, and induced sputum cell counts.

RESULTS

Intranasal fluticasone propionate significantly increased the percentages of patients reporting no nasal blockage, sneezing, or rhinorrhoea during the pollen season, compared with IHFP or intranasal or inhaled placebo. In contrast, only IHFP significantly improved morning peak-flow, forced expiratory volume in 1 second (FEV1) and methacholine PD20, and the seasonal increase in the sputum eosinophils and methacholine responsiveness.

CONCLUSIONS

In patients with pollen-induced rhinitis and asthma, the combination of intranasal and IHFP is needed to control the seasonal increase in nasal and asthmatic symptoms.

Allergic rhinitis: past, present and the future

Allergic rhinitis represents a global health issue affecting between 10% to 25% of the world population, with increasing prevalence over the last decade. Although often trivialized by patients and doctors, allergic rhinitis is a significant cause of morbidity, in addition to its substantial economic impact. While allergic rhinitis is an inflammatory disorder of the upper airways, inflammation alone is insufficient to explain the chronic nature of the disease. An exciting concept which has recently emerged in asthma concerns the role of the bronchial epithelium as a key regulator of airway inflammatory and remodelling responses in asthma. It has been shown by our group that the disruption and alteration in the function of the lower airway epithelium in asthma leads to the generation of a variety of stimuli that lead to the restructuring of the airway wall. This raises interesting questions regarding a similar role for the upper airway epithelium in allergic rhinitis. This review aims to interpret past and current research into allergic rhinitis, and to address specific areas where future research is warranted, particularly in relation to the possibility of an altered upper airway epithelial phenotype in allergic rhinitis.

Local and systemic eosinophilia in patients undergoing endoscopic sinus surgery for chronic rhinosinusitis with and without polyposis

Eosinophils play a key role in the pathophysiology of sinonasal polyposis; their role in chronic rhinosinusitis without polyposis is less clear. To investigate this further, we biopsied diseased sinonasal tissue from 116 patients undergoing endoscopic sinus surgery and normal nasal mucosa from 24 controls. The patients were grouped, according to the nasal endoscopic appearance of their disease, into four clinical groups: chronic rhinosinusitis with no polyps, grade 1 polyps, grade 2 polyps, and grade 3 polyps. We also measured the peripheral blood eosinophil count. Histological analysis of the inflammatory cell content of the biopsies was carried out. The percentage of eosinophils in tissue from each of the clinical groups was significantly higher than that from the controls. There was no significant difference between the percentage of eosinophils in any of the clinical groups, but a trend. Peripheral eosinophil count increased with increasing severity of nasal disease.

Effect of endosinusal treatment on cellular markers in mild and moderate asthmatics

OBJECTIVE

To determine the efficacy of topical endosinusal treatment in terms of reduction in activation of inflammatory cells and asthma/rhinosinusitis symptoms in patients with asthma and chronic rhinosinusitis (CRS).

MATERIAL AND METHODS

Eighteen mild-to-moderate asthmatics with CRS were subjected to antral sinoscopy and endosinusal treatment with 2 mg of dexamethasone and 40 mg of gentamicin per maxillary sinus for 7 days. Sinus lavage and serum samples were taken before and after the treatment and bacteriological swabs from the sinuses were taken at the time of inclusion in the study. Subjective scores for CRS symptoms and forced expiratory volume in 1 s (FEV1) were tested at inclusion and after 30 days. Levels of eosinophil cationic protein (ECP), tryptase and myeloperoxidase (MPO) were analyzed in serum and sinus fluid before and after the treatment.

RESULTS

ECP and tryptase levels were significantly reduced in both serum and sinus fluid, but serum MPO did not show significant changes after the treatment. MPO in sinus lavage was reduced only in moderate asthmatics. Subjective scores for CRS and FEV1 were significantly improved for the whole group. ECP, usually used as a parameter for asthma staging, was mostly affected at the systemic level, whilst tryptase was more markedly reduced at the local level.

CONCLUSION

The topical endosinusal treatment used in this clinical study significantly reduced activation of eosinophils and mastocytes, improved FEV1 and reduced symptoms of CRS in mild-to-moderate asthmatics.

Health care costs of allergic rhinitis-associated conditions vary with allergy season

BACKGROUND

Studies have documented how allergic respiratory symptoms vary with allergen levels, but the impact of allergen levels on health care expenditures for allergy-related conditions has never been shown using actual data on outdoor allergen levels. Evidence linking respiratory allergy to comorbid conditions has also been scanty.

OBJECTIVE

To investigate the link between respiratory allergy and presumably associated conditions by documenting seasonal patterns in their severity and co-occurrence, and to suggest a plan for future research.

METHODS

A retrospective, cross-sectional analysis of medical claims data from 1995 to 1996 were linked to monthly data from federal counting stations on outdoor allergen levels. Participants were employed persons and their dependents, living within 15 miles of an allergen-counting station, continuously enrolled in a health plan for 1995 and 1996, and identified through medical claims data as having asthma, allergic rhinitis (AR), migraines, sinusitis, tonsillitis, otitis media, depression, or anxiety disorder.

RESULTS

All conditions studied were more likely to occur during allergy season than during nonallergy season. For persons with health care claims for a condition of interest in both seasons, total health care costs during allergy season were significantly higher than during nonallergy season. Predicted condition-related expenditures were higher in allergy season for every condition even after controlling for the effect of AR.

CONCLUSION

Allergy effects appear to extend beyond AR symptoms. Other conditions may be affected by outdoor allergen levels even in the absence of AR symptoms, implying that these conditions may be etiologically related to allergy, irrespective of their co-existence with allergic rhinitis, further implying that allergic sensitization can independently affect different parts of the respiratory tract as well as the brain.

Human nasal allergen provocation for determination of true allergic rhinitis: methods for clinicians

The nasal provocation test (NPT) could be more extensively used in the diagnosis of allergic rhinitis by practicing physicians. However, the procedure has not been standardized, and has mainly been utilized for scientific purposes in the US. This review illustrates a wide variety of techniques and approaches to dosing and concentration of allergen extracts, and delivery systems. It also outlines the lack of a unified outcomes-evaluation system, including clinical symptom scores and nasal patency measurements, in different countries. NPT is a safe, simple, and useful method when conducted with the consideration of indications and contraindications. Standardized NPT has the potential to become a more frequently used additional clinical test in the diagnosis of allergic rhinitis.

Cetirizine, a second-generation H1 antagonist, modulates Rantes and MCP-1 levels in allergic rhinitis

Chemokines and their receptors are involved in several allergic diseases. We measured RANTES and MCP-1 levels in sera of allergic rhinitis patients, and also we evaluated the effect of cetrizine, a second-generation H1 antagonist, on these chemoattractant proteins. 15 subjects were studied (10 males and 5 females; mean age: 26.7 years). They were suffering from perennial or seasonal allergic rhinitis induced by Dermatophagoides pteronyssinus (8 patients) or by grasses (7 patients). RANTES and MCP-1 serum levels were detected with an enzyme immunoassay before and after two weeks of treatment with 10 mg of cetirizine daily, and again after two weeks of washout. Baseline serum levels of RANTES and MCP-1 chemokines were significantly higher (p &lt; 0.02 and p = 0.007, respectively) in allergic patients than in the healthy control group. Cetirizine resulted in a significant decrease in RANTES (p &lt; 0.02) and MCP-1 (p = 0.003) versus baseline values. There is an increase in RANTES and MCP-1 in allergic rhinitis, which is counteracted by cetirizine.

Surface-active phospholipid: a Pandora's box of clinical applications. Part I. The lung and air spaces

Almost everywhere in the body there are phospholipids, not only comprising the lipid bilayer of membranes, but also in the free state. What is seldom appreciated, except in respirology, is that these 'free' phospholipids are unusual in that many are highly surface active. Surface activity is a property of certain substances (surfactants), conferred by their molecular constitution and configuration, which predisposes them to locate at interfaces because, in doing so, they reduce interfacial energy. When adsorbed (reversibly bound) to solid surfaces, surfactants can impart many highly desirable properties that have been widely studied and long accepted in the physical sciences, while their commercial applications have withstood the test of time. These desirable properties include lubricity (boundary lubrication), release (antistick) and dewatering, while providing a barrier to corrosion, abrasion, solute transmission and to biological microorganisms. Many of these offer obvious roles for surface-active phospholipid (SAPL), ranging from a corrosion inhibitor in the stomach to a load-bearing lubricant in the joints. This opens a veritable 'Pandora's box' of potential clinical applications. Part I of this review challenges traditional beliefs in respirology that 'surfactant' is unique to the lung and, moreover, that its actions are confined to the liquid-air interface. Evidence is discussed that, by binding to alveolar epithelium, SAPL imparts semi-permeability needed before channels pumping ions can also pump water vital for maintaining fluid balance. Evidence is also reviewed for a lining to upper airways, sinuses and Eustachian tube where it can act like a standard release agent.

Early treatment of perennial rhinitis with budesonide or cetirizine and its effect on long-term outcome

BACKGROUND

Perennial rhinitis is a common disease that has many similarities with bronchial asthma. Early treatment with inhaled steroids has improved asthma symptoms, lung function, and bronchial hyperreactivity, but it has not been studied in perennial rhinitis.

OBJECTIVE

The main objective was to determine whether early introduction of long-term daily intranasal steroid treatment would have a positive effect on the clinical course and outcome of perennial rhinitis compared with the effect of an antihistamine. A secondary objective was to compare the clinical efficacy of intranasal budesonide and oral cetirizine.

METHODS

One hundred forty-three adult patients with newly detected perennial allergic or nonallergic eosinophilic rhinitis of 1 to 3 years' duration were randomized to receive budesonide dry powder, 400 microg (delivered dose of 280 microg) intranasally, or cetirizine, 10 mg orally, once daily for 1 year. At the end of the double-blind treatment period, medication was stopped, and the patients were followed for another year, during which time they could use 14-day courses of intranasal budesonide as needed to control rhinitis relapses. The main outcome measures were the time to first relapse and the number of relapses during the second year. Nasal symptom scores, nasal smear eosinophilia, and nasal peak expiratory flow were used to compare the clinical efficacy of the 2 treatments.

RESULTS

During the randomized phase of the study, budesonide was significantly more effective than cetirizine in relieving nasal symptoms. Nasal peak expiratory flow improved significantly in budesonide-treated patients compared with in patients receiving cetirizine. After discontinuation of randomized treatment, 38% of budesonide-treated and 56% of cetirizine-treated patients had a relapse within the first month (P =.04). The median time to first relapse was longer in budesonide-treated patients than in cetirizine-treated patients (62 vs 20 days), although the difference was not significant. Fourteen-day courses of budesonide provided effective control of relapses; the mean number of relapses was 4.0 versus 5.4 in the groups previously treated with budesonide or cetirizine, respectively. Both treatments were well tolerated throughout the study.

CONCLUSIONS

Budesonide is significantly more effective than cetirizine in controlling perennial rhinitis. After stopping treatment, budesonide better prevents relapses for 1 to 2 months compared with cetirizine. Periodic therapy with budesonide may be sufficient to control symptoms in most patients who have relapses.

Treating allergic rhinitis in patients with comorbid asthma: the risk of asthma-related hospitalizations and emergency department visits

BACKGROUND

Although asthma and allergic rhinitis commonly occur together, the nature of the association has yet to be determined. Treatments for one condition could potentially alleviate the coexisting condition.

OBJECTIVE

Patients with both allergic rhinitis and asthma were studied to test the hypothesis that treating allergic rhinitis reduces health care utilization for co-morbid asthma.

METHODS

A retrospective cohort study was carried out with 1994-1995 MarketScan claims data. The cohort was limited to patients with both allergic rhinitis and asthma, aged 12 to 60 years, who were continuously enrolled and had no evidence of chronic obstructive pulmonary disease. Allergic rhinitis treatment and asthma-related events (hospitalizations and emergency department visits) were identified. An incidence density ratio (IDR) associated with exposure to allergic rhinitis treatment was calculated. A multivariate Poisson regression was estimated, and the parameter estimates were transformed into IDRs for each explanatory variable. An allergic rhinitis treatment indicator was included in all regressions.

RESULTS

The study sample population consisted of 4944 patients with allergic asthma, approximately 73% of whom were treated for their allergic rhinitis. Asthma-related events occurred more often for the untreated group compared with the treated group, 6.6% compared with 1.3%. An IDR of 0.49 for the treatment group (P =.001) indicates that the risk of an asthma-related event for the treated group was about half that for the untreated group.

CONCLUSION

In summary, those who were treated for allergic rhinitis have a significantly lower risk of subsequent asthma-related events (emergency department visits or hospitalizations) than those who were not treated.

Matrix metalloproteinases and their inhibitors in the nasal mucosa of patients with perennial allergic rhinitis

BACKGROUND

Allergic rhinitis and asthma show many similarities in their epithelial and inflammatory responses to allergens. However, one notable difference is that disruption and desquamation of the epithelium is a characteristic feature of asthma, whereas in perennial allergic rhinitis the epithelium is intact and thickened. One reason for this might be differing expression of matrix metalloproteinases (MMPs) or their inhibitors (TIMPs). There are few published data on the presence of MMPs or TIMPs in the nasal mucosa in rhinitis.

OBJECTIVE

The purpose of this study was to investigate MMP and TIMP mRNA and protein in nasal mucosa from subjects with perennial allergic rhinitis and from nonrhinitic control subjects.

METHODS

Biopsy specimens of nasal mucosa were taken from 10 well-characterized subjects with perennial allergic rhinitis and 10 nonrhinitic control subjects. MMP and TIMP mRNA was quantified through use of competitive RT-PCR, and protein was detected by means of Western blotting and ELISA.

RESULTS

TIMP-1 mRNA and TIMP-2 mRNA were present in nasal samples, but there was no significant difference between the 2 groups. Only small amounts of MMP-1, -2, -3, and -9 mRNA were detected in the same samples. The corresponding proteins were detected by means of Western blotting. TIMP-1 protein and TIMP-2 protein were quantified in tissue homogenates; there was no significant difference between the 2 groups.

CONCLUSION

Our studies have demonstrated the presence of large amounts of TIMP-1 and TIMP-2 mRNA and protein in nasal mucosa. There is no upregulation of MMPs or changes in TIMP expression in the nasal mucosa of patients with allergic rhinitis.

Allergic rhinitis and asthma in children: disease management and outcomes

Antihistamines and inhaled glucocorticoids, which can be targeted toward multiple points in the "allergic cascade" underlying allergic rhinitis and asthma, extend the promise of enhanced outcomes in children with allergic rhinitis, asthma, or both. Antihistamine therapy confers significant relief of subjective ratings of seasonal and perennial allergic symptoms (e.g., rhinorrhea, congestion, sneezing, pruritus), whereas topical steroids alleviate such discomfort while also improving objective anatomic and functional indices of nasal patency (e.g., nasal peak inspiratory flow). Youngsters with asthma also experience substantial clinical benefits from inhaled steroids, which improve objective measures of pulmonary function and reduce rescue beta 2-agonists for symptom management and quality-of-life enhancement. This paper reviews recent clinical findings on the role of antihistamines and topical corticosteroids in pediatric allergy and asthma management, as well as the favorable effects of these medications on both objective and subjective health outcomes.

Serum Tryptase in Allergic Rhinitis: Effect of Cetirizine Treatment

Activated mast cells release a large range of potent mediators of allergic inflammation, including proteases. The tryptase serum levels were evaluated in 13 subjects suffering from allergic perennial rhinitis. Moreover, the effects of cetirizine treatment on serum tryptase were studied using the UniCap™ tryptase fluoroenzymeimmunoassay.

In allergic patients the serum tryptase values (M±SD: 6.1 ± 2.4 μg/L) were significantly (p < 0.02) higher than the values detected in controls (3.0 ± 1.2 μg/L). In allergic rhinitis, after antihistamine treatment, tryptase values (4.4 ± 1.8 μg/L) decreased significantly (p < 0.001). After two weeks from the cetirizine stop, the tryptase levels increased again (5.5 ± 2.6 μg/l).

The results demonstrate that mast cells are constantly activated in perennial allergic rhinitis. The antihistamine treatment is effective in reducing the tryptase release from mast cells, but the mechanism of action of cetirizine is still to understand.

Desloratadine activity in concurrent seasonal allergic rhinitis and asthma

Seasonal allergic rhinitis (SAR) and asthma, which are frequently comorbid, share some common allergic pathogenic bases. Clinical manifestations of these disorders might therefore be viewed as local manifestations of a systemic inflammatory state. Not only do the onsets of allergic-rhinitis (AR) and asthma symptoms often coincide (within 1 year), but also nasal challenges with SAR allergens can induce airways hyperreactivity (AHR). Eosinophils, which are key effector cells in both SAR and asthma, cause AHR, tissue damage, and neuronal effects through secretion of toxic granule proteins, enzymes, and other mediators. The novel, nonsedating, histamine H1-receptor antagonist, desloratadine, which exerts various favorable effects on the allergic cascade, significantly decreased SAR symptoms (e.g., nasal congestion) and diminished daily beta2-agonist use and improved asthma symptoms, while maintaining pulmonary function, in patients with SAR-asthma who were treated with once-daily desloratadine regimens.

Inflammatory cell and epithelial characteristics of perennial allergic and nonallergic rhinitis with a symptom history of 1 to 3 years' duration

BACKGROUND

Perennial rhinitis is an inflammatory condition of the mucosal lining of the nose that may be caused by allergic and nonallergic mechanisms.

OBJECTIVE

We sought to characterize the cellular pattern and structural changes in the nasal mucous membrane of patients with perennial rhinitis and compare them with those of control subjects.

METHODS

Biopsy specimens were obtained from 27 patients with perennial allergic rhinitis (PAR), from 12 patients with perennial nonallergic rhinitis (PNAR) with eosinophils present in the nasal smear, and from 6 control subjects without rhinitis. In 10 of 27 patients with PAR who were also allergic to pollen, biopsy specimens were taken within the respective season (PARseason). In the other 17 patients, the biopsy was taken outside the pollen season (PARoutside season). Inflammatory cells were identified by using mAbs to their unique granular proteins.

RESULTS

The characteristic feature of perennial rhinitis was the accumulation of activated (degranulated) mast cells and eosinophils in the nasal mucosa. The tissue eosinophil/neutrophil ratio was higher, and the loss of epithelial integrity was greater in all patient groups compared with the control subjects. The extent of epithelial damage was significantly larger in patients in the PARseason group compared with that in the PARoutside season and PNAR groups, which did not significantly differ from each other in this respect. The number of eosinophils and mast cells was higher in the PNAR group compared with the PAR groups. In all patient groups, the number of eosinophils correlated with the loss of epithelial integrity. The number of mast cells did not correlate with the extent of epithelial damage nor did the number of neutrophils, except in patients in the PARseason group.

CONCLUSION

The accumulation of eosinophils and mast cells, as well as loss of epithelial integrity, was characteristic for perennial rhinitis. Loss of epithelial integrity in the nasal mucosa may be a consequence of the activity of accumulated eosinophils.

Epidemiologic evidence for asthma and rhinitis comorbidity

Asthma and rhinitis are often comorbid conditions, and the overall characteristics of the diseases and the treatment options for the disorders are similar. Several recent epidemiologic studies in the general population have provided evidence to strongly associate the development of asthma with a previous history of either allergic or perennial rhinitis. Additional links between asthma and rhinitis include a description of increased aspirin intolerance in both disorders and the observation that most subjects with occupational asthma experience rhinitis. Further, the likelihood of the development of asthma is much higher in individuals with both perennial and seasonal rhinitis than for individuals with either condition alone. Asthma and rhinitis were found to be comorbidities regardless of atopic state, and perennial rhinitis has been associated with an increase in nonspecific bronchial hyperresponsiveness. Several studies have identified rhinitis as a risk factor for asthma, with the prevalence of allergic rhinitis in asthmatic patients being 80% to 90%. These studies and others demonstrate that the coexistence of asthma and allergic rhinitis is frequent, that allergic rhinitis usually precedes asthma, and that allergic rhinitis is a risk factor for asthma. Finally, studies that have examined the age of onset of atopy as a confounding factor for the development of asthma and allergic rhinitis have suggested that early age atopy may be an important predictive factor for respiratory symptoms that continue into late childhood. In conclusion, rhinitis and asthma are strongly associated, and rhinitis has been identified as a risk factor for asthma.

Sinusitis and its relationship to asthma. Can treating one airway disease ameliorate another?

In a large percentage of patients with upper airway disease, asthma and sinusitis occur concomitantly. As many as 88% of patients with asthma exhibit the symptoms of rhinitis, and half of rhinitic patients have asthma. In this article, Dr Muller explores the interrelationship of sinusitis and asthma, including characteristics, mechanisms of action, and diagnosis, and provides suggestions for optimal treatment of both.

Suppression of neural activity of bronchial irritant receptors by surface-active phospholipid in comparison with topical drugs commonly prescribed for asthma

BACKGROUND

Much indirect evidence has been put forward previously in support of the concept that surface-active phospholipid (SAPL) normally masks irritant receptors in the lungs and upper respiratory tract; but this physical barrier is deficient in asthmatics, imparting hyperresponsiveness of the bronchoconstrictor reflex.

OBJECTIVE

To determine whether exogenous SAPL applied to bronchial mucosa reduces the sensitivity of irritant receptors to a standard challenge used clinically to diagnose asthma and to compare the effects with those of corticosteroids and beta-stimulation.

METHODS

Nerve fibres in the vagi were monitored to record action potentials from irritant receptors identified in the upper airways of rat lungs in response to a methacholine challenge. SAPL in the form of dipalmitoyl phosphatidylcholine (PC) and phosphatidylglycerol (PG) - 7 : 3 PC:PG - was applied as a fine dry powder to enhance surface activity and, hence, chemisorption to epithelium. Comparison was also made with clinical doses of i.v. hydrocortisone and instilled salbutamol together with liquid or solid controls, as appropriate.

RESULTS

Neural activity of irritant receptors was found to be significantly (P = 0.0018) decreased by topical SAPL by 35.8% in response to a methacholine challenge in contrast to an increase of 11.2% in response to a solid (lactose) control. Instilled salbutamol and i.v. hydrocortisone also decreased responses to the same challenge by 43.4% and 14.7%, respectively, in contrast to a liquid (saline) control which increased by 24.5%.

CONCLUSIONS

Surface-active phospholipid has an appreciable effect upon irritant receptors in rat airways, reducing neural response to a methacholine challenge by an amount comparable to that of Salbutamol. These results support the concept of SAPL masking bronchial irritant receptors and warrant placebo-controlled clinical trials of this dry powder as a means of controlling asthma without the side-effects of current medication. Other possible roles discussed for the SAPL epithelial barrier include the exclusion of viruses and allergens.

Mizolastine is effective and well tolerated in long-term treatment of perennial allergic rhinoconjunctivitis. Riperex Study Group

The aim of this study was to determine the long-term efficacy and safety of mizolastine, a new second-generation antihistamine with European approval, in the treatment of perennial allergic rhinoconjunctivitis. In this study, 141 patients were treated with once-daily mizolastine 10 mg or 15 mg in a 5-month open-label extension of a 1-month double-blind, placebo-controlled trial, which assessed once-daily mizolastine 10 mg. Mizolastine significantly reduced the nasal subscore (sneezing, rhinorrhoea, itch; end-baseline +/- SD, -2.5 +/- 6.3), nasal obstruction (-1.2 +/- 2.6) and rhinoscopy scores (-1.3 +/- 2.6), and improved ocular and total nasal scores after 6 months' treatment. Improvement was maintained for the duration of the study with no loss of drug efficacy. Adverse effects were mild with no specific effects associated with prolonged use. These results clearly demonstrate that mizolastine is effective and well tolerated in the long-term treatment of perennial allergic rhinoconjunctivitis. The significant clinical improvement in nasal blockade may reflect mizolastine's histamine/5-lipoxygenase dual inhibition.

Eosinophils are a feature of upper and lower airway pathology in non-atopic asthma, irrespective of the presence of rhinitis

BACKGROUND

Asthma and rhinitis often co-exist and there are data to suggest that they may be two ends of the same disease spectrum. Immunohistochemical studies have shown that eosinophilia in the airways is a feature of rhinitic patients without asthma.

OBJECTIVE

The aim of our study was to examine whether cellular infiltration exists in the nasal mucosa of asthmatics even in the absence of symptoms and signs of rhinitis.

METHODS

Nasal mucosa biopsies were taken from 27 non-atopic subjects and comprised nine asthmatic rhinitic patients (AR), eight asthmatic non-rhinitic patients (ANR) and 10 healthy control subjects (N). Bronchial mucosa biopsies were also taken simultaneously from some of the patients (n = 10) to determine whether there was an association between cellular infiltration in the nose and the lungs. The alkaline phosphatase-anti-alkaline phosphatase (APAAP) method was used on 6 microm thick cryostat sections using monoclonal antibodies against T cells (CD4, CD8), eosinophils (EG2) and mast cells (mast cell tryptase). Slides were counted blind and results expressed as cells per field.

RESULTS

The results showed that eosinophil counts were higher in both asthma groups compared with control nasal biopsies (median values AR 8.3, ANR 9.2, N 2.1 cells per field, P < 0.01). Furthermore, there was a significant correlation between eosinophil cell counts in the nose and the airways (r = 0.851 P < 0.001). No differences in eosinophil numbers were detected between the two groups of asthmatics. Also, no differences were noted for any other cell type (i.e. CD4, CD8, tryptase) among the three study groups.

CONCLUSIONS

These results show that eosinophil infiltration was present in the nasal mucosa of asthmatic patients even in the absence of rhinitis, and add further support to the hypothesis that asthma and rhinitis are clinical expressions of the same disease entity.

An alternative view of the role(s) of surfactant and the alveolar model

Currently, the study of surfactant proteins is much in vogue, but, in the early days, the physics underlying surfactant function was treated somewhat superficially, leaving assumptions that have become culturally embedded, such as the "bubble" model of the alveolus. This review selectively reexamines these assumptions, comparing each combination of alveolar model and role of surfactant for compatibility with the major features of pulmonary mechanics and alveolar stability, morphology, and fluid balance.

A 12-week, placebo-controlled study of the efficacy and safety of ebastine, 10 and 20 mg once daily, in the treatment of perennial allergic rhinitis. Multicentre Study Group

This double-blind, placebo-controlled, multicentre study investigated the ability of ebastine, 10 and 20 mg once daily, to control symptoms of perennial allergic rhinitis (PAR) over a 12-week period, and assessed additional benefits of the 20-mg dose. Following a 2-week baseline period, patients (12-63 years) were randomized to treatment with ebastine 10 mg (n=88) or 20 mg (n=102), or placebo (n=100). Patients scored symptom severity (0-3) twice daily, and mean changes from baseline scores showed ebastine to be significantly effective in week 1. Control of symptoms persisted over the 12 weeks, the average daily total nasal symptom score for nasal stuffiness plus nasal discharge plus sneezing plus itchy nose being reduced by both doses, with statistical significance at 20 mg (P=0.015 vs placebo) despite decreased usage of sodium cromoglycate rescue medications. Patient and clinician final opinions of treatment also significantly favoured ebastine, both 10 and 20 mg, over placebo. No serious adverse events occurred, and study treatments were well tolerated with a low incidence of central nervous system-related adverse events and headache. In conclusion, ebastine 10 or 20 mg once daily was rapidly effective in relieving symptoms of PAR in adult and adolescent patients; additional benefits of the 20-mg dose became apparent in the longer term.

Allergic rhinitis and rhinosinusitis. Is there a connection between allergy and infection?

Each year allergic rhinitis and rhinosinusitis account for millions of office visits and billions of dollars spent on prescription and nonprescription drugs. Although the causes and symptoms of these two ailments differ, there is evidence that they are linked. The authors explain how effective control of allergy symptoms can reduce the incidence and severity of rhinosinusitis.

Mizolastine therapy also has an effect on nasal blockade in perennial allergic rhinoconjunctivitis. RIPERAN Study Group

BACKGROUND

Mizolastine is a new, nonsedating antihistamine with additional anti-inflammatory properties, providing relief in allergic rhinitis and urticaria. The aim of this study was to determine the efficacy and safety of 10 mg o.d. mizolastine given to patients with perennial allergic rhinoconjunctivitis.

METHODS

This double-blind, placebo-controlled study involved 257 patients suffering from the disease for more than 10 years. They were allocated, after a 1-week placebo run-in, to receive mizolastine (n = 133) or placebo (n = 124) for 4 weeks.

RESULTS

Mizolastine-treated patients showed significantly greater alleviation of nasal symptoms, with a mean decrease of 36% compared with pretreatment score, compared to a mean decrease of 10% in placebo patients (P < 0.001). Nasal blockade responded favorably to mizolastine compared to placebo and was associated with a significant reduction in rhinoscopy findings (P = 0.030). Likewise, the mean ocular symptom score decreased 40% in mizolastine-treated patients compared to 7% in the placebo group (P < 0.003). The safety profile of mizolastine was satisfactory and similar to that of placebo.

CONCLUSIONS

In patients suffering from perennial allergic rhinoconjunctivitis, mizolastine is a safe and potent treatment. Mizolastine's pronounced effect on nasal blockade could possibly be linked to its anti-inflammatory properties.