Incidence of grass and weed sensitization in Bangkok, Thailand: a clinical study

Background

Allergic rhinitis (AR) is a prevalent public health concern globally, significantly impacting quality of life. In Thailand, the prevalence of AR is rising, with grass and weed pollen identified as primary outdoor triggers.

Objectives

This study aimed to (1) assess patterns of pollen sensitization in Thai AR patients and (2) investigate correlations between demographics/clinical data and SPT results.

Methods

A total of 121 individuals aged ≥18 years with clinically diagnosed AR were recruited. Skin prick testing (SPT) was performed using a panel of commonly encountered tropical grass and weed pollen extracts. SPT wheal sizes and clinical symptom scores were recorded. Correlations between SPT outcomes and symptom scores were analyzed.

Results

Among the participants, 104 (85.95%) exhibited positive SPT reactions to at least one pollen type. Nutsedge (76/121), para grass (57/121), and Bermuda grass (48/121) were the most frequently identified allergens. Hurricane grass elicited the strongest reaction, evidenced by the highest average wheal size (6.2 mm). Poly-sensitization was observed in 77 (63.6%) of the SPT-positive individuals, with most cases involving two different pollen extracts (35/77). Notably, AR severity positively correlated with both average wheal size and the number of positive SPT tests.

Conclusion

This study highlights nutsedge, para grass, and Bermuda grass as major allergenic pollen sources for Thai AR patients. Including nutsedge, hurricane grass, and careless weed in clinical SPT panels is recommended for improved diagnostic accuracy. Additionally, the positive correlation between AR severity and pollen reaction strength emphasizes the importance of implementing patient education and avoidance strategies.

Phase III study of Phlai capsules in the treatment of allergic rhinitis: A randomized, double-blind, placebo-controlled trial

BACKGROUND

Preclinical studies demonstrated anti-inflammatory effects of Zingiber montanum (J.König) Link ex Dietr.(Phlai). However, its clinical effect on allergic rhinitis (AR) is not evident.

OBJECTIVE

We sought to assess the efficacy and safety of Phlai for treating AR.

METHODS

A phase 3, randomized, double-blind, placebo-controlled study was conducted. Patients with AR were randomized into three groups and received Phlai 100 mg or Phlai 200 mg or placebo once a day for four weeks. The primary outcome was a change in the reflective total five symptom score (rT5SS). The secondary outcomes were the change in the instantaneous total five symptom score (iT5SS), the reflective individual symptom scores (rhinorrhea, nasal congestion, sneezing, itchy nose, itchy eyes), Rhinoconjunctivitis Quality of Life-36 Questionnaire (RCQ-36) score, peak nasal inspiratory flow (PNIF), and adverse events.

RESULTS

Two hundred and sixty-two patients were enrolled. Compared with placebo, Phlai 100 mg improved rT5SS [adjusted mean difference (aMD) -0.62; 95%CI -1.22, -0.03; p = 0.039], rhinorrhea (aMD -0.19; 95%CI -0.37, 0.002; p = 0.048), itchy nose (aMD -0.24; 95%CI -0.43, -0.05; p = 0.011), and itchy eyes (aMD -0.19; 95%CI -0.36, -0.02; p = 0.033) at week 4. Nasal obstruction, sneezing, iT5SS, overall RCQ-36 score, PNIF did not reach statistical significance. Phlai 200 mg did not bring additional benefits compared to 100 mg. Adverse events were similar among groups.

CONCLUSIONS

Phlai was safe. At four weeks, there were small improvements in rT5SS, together with the individual symptoms of rhinorrhea, itchy nose, and itchy eyes.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Allergen immunotherapy for respiratory allergies in clinical practice: A comprehensive review

Allergen-specific immunotherapy (AIT) is the only treatment that modifies the underlying pathophysiology of IgE-mediated allergic diseases. Evidence shows the efficacy in achieving better control of the symptoms and reduction in medication use in patients with allergic rhinoconjunctivitis and/or asthma. It should be used in association with proper pharmacotherapy for at least three years. The benefits are sustained for several years after discontinuation of treatment. Moreover, it may prevent the development of new sensitization and progression of disease from allergic rhinitis to asthma in children. The favorable efficacy of AIT is associate to the appropriate selection of patients, allergen extracts, adherence, and duration of treatment. Safety during AIT is another concerning issue. AIT has an acceptable safety profile if administered under the appropriate circumstances. Future studies investigating the prescription, efficacy, and safety need to be developed. The new application routes, use of adjuvants, modification of allergens, and use of biologics are currently under evaluation. Moreover, there is an urgent need for real-world data in developing countries regarding the cost-effectiveness analysis, and optimization of AIT schedules and products, so that clinical practice and implementation of AIT for respiratory allergic diseases can be effective and safe.

LNIT-Local nasal immunotherapy in allergic rhinitis: revisited evidence and perspectives

PURPOSE OF REVIEW

Allergen immunotherapy (AIT) is a personalized treatment approach for the allergic airway disease. The most common routes of administration are subcutaneous and sublingual. Local nasal immunotherapy (LNIT) presents another alternative route for allergen desensitization. Nasal mucosa is the first entry site of pathogens and numerous lymphoid organs are located in this area, making LNIT a favorable method for triggering immune tolerance. LNIT has shown promising results in reducing symptoms and medication use in allergic rhinitis patients. Over time, difficulties in dosing adjustments have made this method less popular. Recent advances in intranasal drug delivery systems warrant re-examination of LNIT as a viable option for the treatment of the allergic airway disease.

RECENT FINDINGS

The scope of the review includes evidences of LNIT in human trials including comparison with placebo and conventional method of immunotherapy. Recent articles regarding the mechanism of LNIT and the challenges of intranasal drug delivery are reviewed. Advances in the LNIT delivery system which have overcome previous limitations demonstrate promising effects.

SUMMARY

LNIT presents a judicious alternative for noninjection AIT. The evidences from previous clinical trials and the novel improvement of drug delivery system will lead into the future allergen vaccine production.

Asia-Pacific survey of physicians' perceptions and managements of chronic rhinosinusitis

BACKGROUND

The diagnosis and management of patients with chronic rhinosinusitis (CRS) may vary between otolaryngologists and allergists. Moreover, the adherence of different practitioners to European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 guideline recommendations has not been previously ascertained in Asia-Pacific regions.

OBJECTIVE

Different specialists' perceptions and managements of CRS in Asia-Pacific regions were assessed in an attempt to gauge these practices against EPOS 2020 guidelines.

METHODS

A transregional, cross-sectional survey was conducted to assess otolaryngologists' and allergists' perceptions and managements of CRS with regard to diagnosis, management and adherence to EPOS 2020 guidelines.

RESULTS

Sixteen physicians in Asia-Pacific regions responded to the questionnaire. A total of 71.4% of otolaryngologists preferred to diagnose CRS with a combination of positive nasal symptoms and nasal endoscopy plus sinus CT, whereas 22.2% of allergists took such criterion to diagnose CRS. Compared to allergists, otolaryngologists more often considered the endotype classification (85.8% versus 55.5%). For the preferred first-line treatment, in addition to intranasal corticosteroids recommended by all respondents, 66.7% of allergists preferred antihistamines, whereas 71.4% of otolaryngologists preferred nasal saline irrigation. Regarding the proper timing of surgery, 71.5% of otolaryngologists reported 8-12 weeks of treatment after the initiation of medication, while more than half of the allergists recommended 4-6 weeks of medical treatment.

CONCLUSIONS

This survey shows that variable perceptions and practices for CRS may exist between physicians with different specialties and highlights the need for increased communication and awareness between otolaryngologists and allergists to improve the diagnosis and treatment of CRS.

Local nasal immunotherapy for allergic rhinitis: A systematic review and meta-analysis

INTRODUCTION

Local nasal immunotherapy (LNIT), an alternative noninjection immunotherapy method, is theoretically an efficient method for inducing immunotolerance directly in the affected organ. LNIT is more convenient and less invasive than injection immunotherapy, with fewer systemic reactions. The development of adjuvants to overcome LNIT's limitations raises the possibility of it being an alternative allergen immunotherapy.

OBJECTIVES

To evaluate the clinical and immunological efficacy and safety of LNIT for patients with allergic rhinitis.

METHODS

A systematic search for randomized controlled trials comparing LNIT and placebo was performed using OVID Medline and Embase. Outcomes were total nasal symptom score (TNSS), symptom-medication score (SMS), medication score, immunological assessment, and nasal provocation threshold. Data were pooled for meta-analysis.

RESULTS

A total of 20 studies with 698 participants were included. The LNIT group had greater posttreatment improvement in TNSS, SMS, and medication score than control (TNSS: standardized mean difference [SMD], -1.37 [95% confidence interval [CI], -2.04 to -0.69]; SMS: SMD, -1.55 [95% CI, -2.83 to -0.28]; and medication score: SMD, -1.09 [95% CI, -1.35 to -0.83]). Immunological assessments showed no significant differences in serum-specific IgE (mean difference [MD], 6.35; 95% CI, -4.62 to 17.31), nasal IgE (MD, -0.59; 95% CI, -1.99 to 0.81), or nasal eosinophil cationic protein (MD, 7.63; 95% CI, -18.65 to 33.91). Only serum IgG significantly increased with LNIT (MD, 0.45; 95% CI, 0.20, 0.70). Posttreatment, nasal provocation threshold was higher with LNIT (MD, 27.30; 95% CI, 10.13-44.46). No significant adverse events were reported.

CONCLUSIONS

LNIT is a safe alternative allergen immunotherapy route without significant adverse events. It improves clinical symptoms, reduces medication usage, and increases the nasal provocation threshold.

Pattern of Aeroallergen Sensitization and Quality of Life in Adult Thai Patients With Allergic Rhinitis

The prevalence of allergic rhinitis (AR) is steadily rising in the Thai population, causing a major impact on the quality of life (QoL). Enhancing knowledge on common aeroallergens in the local setting helps in the appropriate prevention and management of AR. In this study, the demographic characteristics, clinical data, aeroallergen sensitization pattern, allergic symptoms, visual analog scale (VAS) score, and QoL are described. We evaluated the association between VAS, QoL, and severity of symptoms, except the aeroallergen sensitization pattern. We retrospectively reviewed the medical records of adult AR patients with a positive skin prick test (SPT) for at least one aeroallergen from January 2018 to May 2020. Standard descriptive and inferential statistics were used for analysis. A total of 366 patients were enrolled. Indoor aeroallergen sensitization and outdoor aeroallergen sensitization were observed in 32% and 7.9% of patients, respectively. Mono-sensitization was noted in 16.9% of patients, while poly-sensitization was noted in 83.1% of patients. Mites (65%) and sedge (39.3%) were the most common indoor and outdoor allergens. Nasal obstruction (74.6%), runny nose (63.7%), and nasal itchiness (61.5%) were the primary symptoms affecting the QoL. The association between VAS and symptom scores showed a trend of association with AR severity (Allergic Rhinitis and its Impact on Asthma [ARIA] classification) and VAS. AR has a significant effect on QoL in all domains of the validated generic (short-form-36, SF-36) and specific (rhino-conjunctivitis QoL questionnaire, Rcq-36) questionnaires. Mite and sedge remain the most common indoor and outdoor aeroallergens. The pattern of sensitization and number of aeroallergens were not associated with AR based on the ARIA guidelines. Meanwhile, symptoms of patients affected the QoL and VAS scores, which can be used as a quick and reliable tool for monitoring and stepping up or stepping down the treatment according to the next-generation guidelines. AR has a significant impact on the QoL of adult Thai patients.

Manila grass (Zoysia matrella) Zoy m 1 allergen may contribute to allergic sensitization in tropical/subtropical regions due to extensive cross-reactivity with other group-1 grass pollen allergens

BACKGROUND

Pollen of grasses in Chloridoideae and Panicoideae subfamilies is a major source of grass group-1 allergens in tropical/subtropical areas. Previously, most studies of subtropical grass pollen allergens have focused on Cynodon dactylon (Bermuda grass-Chloridoideae) and Sorghum halepense (Johnson grass-Panicoideae). However, little information is available about allergenicity of pollen from Zoysia matrella (Manila grass or Zoysia grass-Chloridoideae), which is among the most popular turfgrasses in tropical/subtropical areas.

OBJECTIVE

This study aimed to investigate the IgE reactivity and cross-reactivity of grass group-1 allergen from Z. matrella. In addition, the clinical relevance of Z. matrella in comparison with other species was assessed.

METHODS

IgE reactivity and cross-reactivity between recombinant proteins of group-1 allergen from Z. matrella (Zoy m 1) and C. dactylon (Cyn d 1) were determined by ELISA and immunoblot assays. Clinical relevance of Z. matrella pollen in Thai atopic patients was assessed using its pollen crude extract for skin-prick test, in comparison with extracts from four other pollen species.

RESULTS

The Zoy m 1 had high IgE binding and could interfere with binding to C. dactylon crude extract. In addition, Z. matrella pollen extract elicited positive skin-prick test results comparable to previously reported allergenic species. Group-1 grass pollen allergen was confirmed to be a major allergen from Z. matrella among Thai atopic patients and was officially designated Zoy m 1.0101.

CONCLUSIONS

Zoy m 1 allergen is a major allergen from Z. matrella that cross-reacts with other group-1 grass pollen allergens in the tropical/subtropical region.

Cabbage and fermented vegetables: From death rate heterogeneity in countries to candidates for mitigation strategies of severe COVID-19

Large differences in COVID‐19 death rates exist between countries and between regions of the same country. Some very low death rate countries such as Eastern Asia, Central Europe, or the Balkans have a common feature of eating large quantities of fermented foods. Although biases exist when examining ecological studies, fermented vegetables or cabbage have been associated with low death rates in European countries. SARS‐CoV‐2 binds to its receptor, the angiotensin‐converting enzyme 2 (ACE2). As a result of SARS‐CoV‐2 binding, ACE2 downregulation enhances the angiotensin II receptor type 1 (AT₁R) axis associated with oxidative stress. This leads to insulin resistance as well as lung and endothelial damage, two severe outcomes of COVID‐19. The nuclear factor (erythroid‐derived 2)‐like 2 (Nrf2) is the most potent antioxidant in humans and can block in particular the AT₁R axis. Cabbage contains precursors of sulforaphane, the most active natural activator of Nrf2. Fermented vegetables contain many lactobacilli, which are also potent Nrf2 activators. Three examples are: kimchi in Korea, westernized foods, and the slum paradox. It is proposed that fermented cabbage is a proof‐of‐concept of dietary manipulations that may enhance Nrf2‐associated antioxidant effects, helpful in mitigating COVID‐19 severity.

Prevalence of local allergic rhinitis to Dermatophagoides pteronyssinus in chronic rhinitis with negative skin prick test

BACKGROUND

Local allergic rhinitis (LAR) is a localized nasal allergic response in the absence of systemic atopy that is characterized by local production of specific immunoglobulin E (sIgE), and a positive response to NAPT (nasal allergen provocation test).

OBJECTIVE

The objective of this study is to investigate the prevalence of LAR in adults with chronic rhinitis (CR) and negative skin prick test to Dermatophagoides pteronyssinus (Dp), and to assess the clinical characteristics of LAR, comparing to non-allergic rhinitis (NAR).

METHODS

Patients with history of CR with negative skin prick test (SPT) to Dp were recruited during January 2015-April 2016. Demographic and clinical data were obtained, and then a NAPT with Dp was performed. The immediate response to NAPT-Dp was assessed using clinical symptom score, visual analogue scale, peak nasal inspiratory flow, and acoustic rhinometry. Nasal lavage was evaluated for nasal sIgE and tryptase level.

RESULTS

Sixty-two CR patients were recruited. NAPT-Dp was positive in 15/62 (24.2%) of CR patients. Most LAR patients were female (73.3%), and the mean age of all patients was 36.1 ± 10.4 years. Our evaluation of patient characteristics revealed sneezing to be the only evaluated factor to be statistically significantly different between groups [odds ratio (OR): 7.75, 95% confidence interval (CI): 1.91-31.48; p = 0.002].

CONCLUSIONS

The prevalence of LAR to Dp in Thai adults with CR and negative skin prick test was 24.2%. Most LAR patients had moderate-severe persistent severity. The clinical characteristics of LAR, sneezing was shown to be a significantly dominant symptom in LAR than in NAR.

The international sinonasal microbiome study: A multicentre, multinational characterization of sinonasal bacterial ecology

The sinonasal microbiome remains poorly defined, with our current knowledge based on a few cohort studies whose findings are inconsistent. Furthermore, the variability of the sinus microbiome across geographical divides remains unexplored. We characterize the sinonasal microbiome and its geographical variations in both health and disease using 16S rRNA gene sequencing of 410 individuals from across the world. Although the sinus microbial ecology is highly variable between individuals, we identify a core microbiome comprised of Corynebacterium, Staphylococcus, Streptococcus, Haemophilus and Moraxella species in both healthy and chronic rhinosinusitis (CRS) cohorts. Corynebacterium (mean relative abundance = 44.02%) and Staphylococcus (mean relative abundance = 27.34%) appear particularly dominant in the majority of patients sampled. Amongst patients suffering from CRS with nasal polyps, a statistically significant reduction in relative abundance of Corynebacterium (40.29% vs 50.43%; P = .02) was identified. Despite some measured differences in microbiome composition and diversity between some of the participating centres in our cohort, these differences would not alter the general pattern of core organisms described. Nevertheless, atypical or unusual organisms reported in short-read amplicon sequencing studies and that are not part of the core microbiome should be interpreted with caution. The delineation of the sinonasal microbiome and standardized methodology described within our study will enable further characterization and translational application of the sinus microbiota.

Microbiotyping the Sinonasal Microbiome

This study offers a novel description of the sinonasal microbiome, through an unsupervised machine learning approach combining dimensionality reduction and clustering. We apply our method to the International Sinonasal Microbiome Study (ISMS) dataset of 410 sinus swab samples. We propose three main sinonasal "microbiotypes" or "states": the first is Corynebacterium-dominated, the second is Staphylococcus-dominated, and the third dominated by the other core genera of the sinonasal microbiome (Streptococcus, Haemophilus, Moraxella, and Pseudomonas). The prevalence of the three microbiotypes studied did not differ between healthy and diseased sinuses, but differences in their distribution were evident based on geography. We also describe a potential reciprocal relationship between Corynebacterium species and Staphylococcus aureus, suggesting that a certain microbial equilibrium between various players is reached in the sinuses. We validate our approach by applying it to a separate 16S rRNA gene sequence dataset of 97 sinus swabs from a different patient cohort. Sinonasal microbiotyping may prove useful in reducing the complexity of describing sinonasal microbiota. It may drive future studies aimed at modeling microbial interactions in the sinuses and in doing so may facilitate the development of a tailored patient-specific approach to the treatment of sinus disease in the future.

Pattern of allergic sensitization in chronic rhinitis: A 19-year retrospective study

BACKGROUND

The pattern of allergic sensitization provides data for physicians to take appropriate care of allergic patients.

OBJECTIVE

To analyze the long-term pattern of allergen skin prick test (SPT) sensitization at a single tertiary care hospital in Thailand.

METHODS

Medical records of adult rhinitis patients during 1998 to 2017 were reviewed. Inclusion criteria were chronic rhinitis with positive SPT to at least one aeroallergen in the test panel. Outcome measures were SPT results, clinical symptoms, and their effect on patient quality of life (QoL). Descriptive statistics were used to demonstrate the pattern of sensitization. Multivariate linear regression was used to identify association between evaluated factors and patient QoL.

RESULTS

Six thousand five hundred and seventeen adult patients were included in this study. Mean age was 36.4 & 13.8 years. A majority of patients (59.4%) had positive SPT, and 83.7% of those had polysensitization. Dermatophagoides pteronyssinus and sedge were the most common indoor (54.8%) and outdoor allergens (37.7%), respectively. Compared among the various periods of data collection over a 19-year period, there was no major change in the pattern of sensitization. Considering the most recent data from 2013-2017, the prevalence of sensitization increased from 66.8% to 73.7% (p < 0.001). Clinical symptoms, except sneezing and allergen sensitization, affect QoL of chronic rhinitis patients (p < 0.001).

CONCLUSIONS

House dust mite and sedge are the most common indoor and outdoor allergens. There was no major change in the pattern of sensitization. Almost all allergic symptoms significantly affect QoL.

European Position Paper on Rhinosinusitis and Nasal Polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

Prevalence of nasal carriage of Staphylococcus aureus in allergic rhinitis patients and healthy controls in Thailand

BACKGROUND

Staphylococcus aureus has been proposed as a disease modifier of allergic rhinitis (AR) severity. Although several studies have investigated the prevalence of nasal carriage of S. aureus in healthy controls and AR patients, data from Thailand is scarce.

OBJECTIVE

The aim of this study was to determine the prevalence of nasal carriage of S. aureus in AR patients compared with healthy controls in Thailand.

METHODS

This prospective study enrolled non-AR healthy controls and confirmed AR aged 18-60 years who attended the Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand during June 2013 and December 2013. To detect nasal carriage of S. aureus, nasal swab was used for specimen collection from the nasal vestibule. S. aureus prevalence was compared between groups. All AR patients were assessed for disease severity and quality of life.

RESULTS

The 200 enrolled participants were evenly divided between the AR and healthy control groups. Nasal swab cultures were positive for S. aureus in 20 of 100 subjects in the healthy control group, and in 21 of 100 subjects in the AR group (p = 0.86). Nasal carriage of S. aureus was significantly more prevalent in males than in females (p = 0.01). None of the investigated factors were found to be significantly associated with AR severity among S. aureus-positive AR subjects.

CONCLUSIONS

The 20% prevalence of S. aureus in AR patients is not different from that of healthy controls in Thailand, and is similar to other reported rates. No significant associations with AR severity were identified.

Clinical characteristics and aspirin desensitization in Thai patients with a suggestive history of NSAID-exacerbated respiratory disease

BACKGROUND

Non-steroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (NERD) is characterized by the triad of chronic rhinosinusitis with nasal polyp, asthma, and aspirin (ASA) or NSAID hypersensitivity. Previous study of NERD has rarely been reported in Asian population.

OBJECTIVES

To investigate the clinical characteristics and outcomes of aspirin desensitization (ASAD) in Thai NERD patients.

METHODS

This retrospective chart review included patients with a suggestive history of NERD with or without ASAD from the Adult Allergy Clinic of Siriraj Hospital (Bangkok, Thailand) during January 2008 to December 2018.

RESULTS

Ten NERD patients were recruited. The median age of onset was 30 years. Comorbid atopic diseases were found in 4 patients. Asthma control level was step 3 of the Global Initiative for Asthma (GINA) guideline or greater in all patients. Five patients had reactions to more than one NSAIDs. Ibuprofen was the most common culprit agent. Reactions frequently involved the respiratory and cutaneous systems. Four patients underwent ASAD followed by ingestion of ASA 300-600 mg daily. One patient discontinued ASA after taking ASA 600 mg daily for 3 months due to severe gastrointestinal side effect. The remaining three patients successfully continued ASA 300 mg daily as maintenance to control sino-nasal inflammation and to prevent recurrence of nasal polyp. None of the 4 patients required sinus surgery revision.

CONCLUSIONS

NERD is a difficult-to-treat disease with unique clinical characteristics. ASAD followed by a maintenance dose of ASA 300 mg daily was found to be effective and well-tolerated in most patients.

The prevalence of high risk of obstructive sleep apnea in patients with allergic rhinitis

BACKGROUND

Although allergic rhinitis (AR) has not been acknowledged as a strong risk factor for obstructive sleep apnea (OSA), several pathophysiological linkages between these two conditions have frequently been reported. However, epidemiological data relating to the prevalence of OSA in patients with AR remain scarce.

OBJECTIVE

To investigate the prevalence of patients at high risk for OSA among patients with AR, and to determine the relationship between OSA and severity of AR.

METHODS

Patients aged ≥ 18 years with a diagnosis of AR and positive skin prick test were recruited from the allergy clinic, Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand between October 2014 to November 2015. During routine follow-up, participants were asked to complete the STOP-Bang questionnaire and visual analog scale regarding AR symptoms, including their duration and severity. Patients with STOP-Bang score of ≥ 3 were considered as high risk for having OSA.

RESULTS

Of the 120 AR patients (45 males, 75 females) included, there were 28 patients (19 males, 9 females) who had a STOP-Bang score of ≥ 3 (23.3%), especially for those who had longer duration of AR symptoms (low-risk/high-risk: 60/120 months, p = 0.01). However, no significant relationship was observed between ARIA classification and severity of nasal symptoms of AR for being high risk of OSA.

CONCLUSION

The prevalence of high risk of having OSA in patients with AR was two times higher than that in general Thai population. Early screening and further management for these patients may improve treatment outcomes and quality of life.

Minimal clinically important difference for the rhinoconjunctivitis quality of life questionnaire in allergic rhinitis in Thai population

Background

Clinical measurement of the severity of allergic rhinitis (AR) can be assessed by symptoms score and patient quality of life (QoL). The magnitude of change in both symptoms and patient QoL should be considered in the management of AR.

Objective

The aim of this study was to determine the minimal clinically important difference (MCID) in AR in Thai population.

Methods

This prospective study recruited AR patients that attended our clinic during September 2011 to February 2012. The Rhinoconjunctivitis Quality of Life (Rcq-36) questionnaire was used to evaluate patient QoL. The Global Rating of Change Scale (GRCS) was used to assess improvement or deterioration in condition. The MCID was determined using an anchor-based method based on the GRCS, which was compared to the MCID determined by a distribution-based method based on the standard deviation (SD).

Results

Three hundred seventy-two patients with chronic rhinitis were recruited. Eighty-four of those had positive skin prick test and be diagnosed as AR. Of those, 79 completed the study and were included in the final analysis. A change of 2 points on the GRCS yielded an MCID for overall QoL of 0.21 ± 0.57. When applying the distribution-based method, an SD of 1.5 SD yielded an MCID for QoL of 0.27. For the rhinitis symptoms domain, the MCID was 0.42 ± 0.72.

Conclusions

The MCID for overall QoL and rhinitis symptoms in Thai AR patients was found to be 0.21 ± 0.57 and 0.42 ± 0.72, respectively. MCID can be applied for determining the clinical significance of treatment efficacy in AR.

A Comparison of Endoscopic Culture Techniques for Chronic Rhinosinusitis

Background

Recent evidence suggests that endoscopically obtained cultures from the middle meatus give comparable results to antral puncture for acute sinusitis. The best method for obtaining middle meatal cultures remains somewhat controversial because it has been theorized that specimens obtained with a swab are contaminated easily. This study compares endoscopic culture results from two different methods: swab and aspiration. Specifically, this study sought to determine whether or not the culture contamination rate is higher using the swab versus an aspiration technique.

Methods

One hundred consecutive culture specimens from 81 chronic rhinosinusitis patients were compared. Fifty cultures were obtained using a swab technique (group I) and another 50 cultures were obtained by aspirating pathological material into a sterile suction trap (group II). The patient populations in each group were similar; there were no differences in terms of age, gender, comorbid medical conditions, or prior medical therapy. Cultures were considered contaminated if they yielded normal nasal flora or if rare or few Staphylococcus coagulase-negative colonies grew after no bacteria was identified in gram stain. Staphylococcus aureus, Staphylococcus coagulase-negative, and Pseudomonas aeruginosa were the three most common organisms in both groups.

Results

Gram-negative bacteria were noted in 21/60 (35%) positive cultures. Although the contamination rate of the suction aspiration group (14%) was less than the endoscopic swab group (10%), this did not approach statistical significance (p = 0.75).

Conclusions

Data from this study suggest that endoscopically guided aspiration of pathological material is no better than properly obtained swabs in directing antimicrobial therapy for chronic rhinosinusitis.

Endotyping of Chronic Rhinosinusitis With and Without Polyp Using Transcription Factor Analysis

Inflammation of the nose and paranasal sinus or rhinosinusitis (RS) is a significant global health problem that is both very common and very costly to treat. Previous reports reveal variability in histology and mechanism of inflammation in patients with chronic rhinosinusitis with and without polyp (CRScNP and CRSsNP, respectively). There are various methods and hypothesis that try to explain this variability. Accordingly, the aim of this study was to investigate the incidence of each type of sinonasal inflammation among patients diagnosed with CRScNP or CRSsNP using transcription factor analysis (TFA). This study included mucosa specimens from nose/paranasal sinuses from patients with chronic rhinitis (CR), CRSsNP, or CRScNP that were obtained at the Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand during the June 2009 to May 2012 study period. TFA was employed to measure the following transcription factors: T-box transcription factor (T-bet) for Th1, GATA binding protein 3 (GATA-3) for Th2, retinoic acid-related orphan receptor C (RORC) for Th17, and forkhead box P3 (FOXP3) for Treg. Forty-one subjects (22 males, 19 females) were enrolled, with a mean age of 45.93 ± 13 years. Twenty-six patients were diagnosed with CRScNP, 7 with CRSsNP, and 8 with CR (controls). The majority of CRScNP specimens (76.9%) had eosinophil count greater than 100 cells/high-power field (HPF). Mean eosinophil count was 930.08 ± 1,399 cells/HPF (range: 17-5,570). Th2 transcription factor (GATA-3) was statistically significantly higher in the CRScNP group than in the CRS and control groups (p < 0.001); whereas, Treg transcription factor (FOXP3) was statistically significantly lower in the CRScNP group than in the CRSsNP and control groups (p < 0.001). The transcription factors for Th1 and Th17 (T-bet and RORC, respectively) were not significantly different among the three groups. The result of transcription factor analysis revealed hyperfunction of Th2 in patients with CRScNP, which might result in hypereosinophilic infliltration in the polyps. One explanation for this finding is the decreased activity of Treg. Although environment-host interaction is the most probable hypothesis, the etiology of aberrant adaptive immunity needs to be elucidated.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Glutathione S-transferase (GST) of American Cockroach, Periplaneta americana: Classes, Isoforms, and Allergenicity

Insect glutathione S-transferases (GSTs) play important roles in insecticide/drug resistance and stress response. Medically, GSTs of house dust mites (Dermatophagoides pteronyssinus and Blomia tropicalis) and German cockroach (Blattella germanica) are human allergens. In this study, classes, isoforms and B-cell and allergenic epitopes of GST of American cockroach, Periplaneta americana, the predominant species in the tropics and subtropics were investigated for the first time. Enzymatically active native and recombinant P. americana-GSTs bound to IgE in sera of all P. americana allergic patients that were tested. By gel-based proteomics and multiple sequence alignments, the native GST comprises three isoforms of delta and sigma classes. All isoforms interacted with serum IgE of the cockroach allergic subjects. Molecularly, the protein contains six B-cell epitopes; two epitopes located at β1-α1 and β4-α3 regions bound to patients’ serum IgE, indicating that they are allergenic. P. americana are ubiquitous and their GST can sensitize humans to allergic diseases; thus, the protein should be included in the allergen array for component resolved diagnosis (CRD) of allergic patients, either by skin prick test or specific IgE determination. The GST is suitable also as a target of environmental allergen detection and quantification for intervention of cockroach sensitization and allergic morbidity.

Reliability and validity study of Sino-nasal outcome test 22 (Thai version) in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is one of common health conditions that affects patients' health-related quality of life. Our purpose is to assess the reliability and validity of Thai-version of Sino-Nasal Outcome Test 22 in chronic rhinosinusitis.

METHODS

Permission for translation of SNOT-22 from English language to Thai language was obtained from the developer. The translation process was done based on the international standard of translation method. A total of 80 subjects were recruited into the study and divided into two groups comprising of 50 patients with chronic rhinosinusitis and 30 healthy volunteers. Cronbach's α and Intraclass correlation coefficient were evaluated for its reliability. Validity test was evaluated against VAS score, SF-36 (Thai version) questionnaire and CT scan (based on Lund-Mackay score). Responsiveness was assessed between pre-operative and post-operative scores in 34 patients.

RESULTS

The Thai version of SNOT-22 showed good reliability according to high value of Cronbach's α coefficient (r = 0.929) and intraclass correlation coefficient (r = 0.935). It also showed good validity by its ability to differential the patients with chronic rhinosinusitis from normal (p < 0.001), and different severity of symptoms (p < 0.05). In addition, the SNOT-22 Thai version also showed good responsiveness when compared between pre-operative and post-operative scores (p < 0.001) and also well-performed in effect size calculation (1.37).

CONCLUSION

We demonstrated that Thai -version of SNOT-22 has good reliability and validity, suitable for evaluation of chronic rhinosinusitis symptoms together with severity of the disease and response to treatment.

TRIAL REGISTRATION

Thai clinical trials registry TCTR20170320003. Date of registration 20/03/2017 (retrospectively registered).

Alteration of -656(G/T) and -607(C/A) polymorphisms in interleukin-18 (IL-18) gene in house dust mite-sensitive allergic rhinitis patients in Thailand

Allergic rhinitis (AR) is an IgE-mediated inflammation of the nasal membranes, which is naturally triggered by aeroallergens. House dust mites (HDM) are the most common inhalant allergens. Interleukin-18 (IL-18) has been established as an essential cytokine that can activate the generation of IgE. This randomized controlled study aimed to identify the possible relationship of the genetic variations in the IL-18 gene with AR in mite-sensitive Thai patients. Study subjects consisted of 150 AR patients and 50 normal participants. Genomic DNA of 30 randomized AR patients and 30 randomized controls were screened by sequencing for the selection of candidate single nucleotide polymorphisms (SNPs), and further analyzed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay for all subjects. The following five SNPs were detected in the IL-18 gene: -656 G/T, -607 C/A, and -137 G/C in promoter 1 and -920 C/T and -373 C/G in promoter 2. The results showed that -656 G/T and -607 C/A SNPs were significantly correlated with IgE levels specific to Dermatophagoides pteronyssinus (Der p) allergen (P = 0.045 and P = 0.045, respectively), and significant differences were observed in the genotype distribution of AR patients when compared with controls [P = 0.044 and P = 0.044, respectively; odds ratios (ORs): 1.941 (95%CI, 1.014-3.715) and 1.941 (95%CI, 1.014-3.715), respectively]. Our findings indicate that the IL-18 alleles, -656T (rs1946519) and -607A (rs1946518), might be associated with the higher production of Der p allergen-specific IgE in mite-sensitive AR patients.

Erratum to: Risk and safety requirements for diagnostic and therapeutic procedures in allergology: World Allergy Organization Statement

[This corrects the article DOI: 10.1186/s40413-016-0122-3.].

Risk and safety requirements for diagnostic and therapeutic procedures in allergology: World Allergy Organization Statement

One of the major concerns in the practice of allergy is related to the safety of procedures for the diagnosis and treatment of allergic disease. Management (diagnosis and treatment) of hypersensitivity disorders involves often intentional exposure to potentially allergenic substances (during skin testing), deliberate induction in the office of allergic symptoms to offending compounds (provocation tests) or intentional application of potentially dangerous substances (allergy vaccine) to sensitized patients. These situations may be associated with a significant risk of unwanted, excessive or even dangerous reactions, which in many instances cannot be completely avoided. However, adverse reactions can be minimized or even avoided if a physician is fully aware of potential risk and is prepared to appropriately handle the situation. Information on the risk of diagnostic and therapeutic procedures in allergic diseases has been accumulated in the medical literature for decades; however, except for allergen specific immunotherapy, it has never been presented in a systematic fashion. Up to now no single document addressed the risk of the most commonly used medical procedures in the allergy office nor attempted to present general requirements necessary to assure the safety of these procedures. Following review of available literature a group of allergy experts within the World Allergy Organization (WAO), representing various continents and areas of allergy expertise, presents this report on risk associated with diagnostic and therapeutic procedures in allergology and proposes a consensus on safety requirements for performing procedures in allergy offices. Optimal safety measures including appropriate location, type and required time of supervision, availability of safety equipment, access to specialized emergency services, etc. for various procedures have been recommended. This document should be useful for allergists with already established practices and experience as well as to other specialists taking care of patients with allergies.

The proportion of local allergic rhinitis to Dermatophagoides pteronyssinus in children

BACKGROUND

Local allergic rhinitis (LAR) is diagnosed by the positive response to nasal allergen provocation test (NAPT) to aeroallergen and/or local synthesis of specific IgE (sIgE). This entity is found in half of the adults with non-allergic rhinitis (NAR). In children, very few data of the prevalence and characteristics of LAR were reported.

METHODS

Children 8-18 years with NAR were recruited. A NAPT with Dermatophagoides pteronyssinus extract (NAPT-Dp) at 200, 600, and 2000 AU/ml, respectively, at 15-min interval was performed. The immediate response was assessed using the clinical symptom score, peak nasal inspiratory flow (PNIF), and acoustic rhinometry (ARM). The nasal tryptase and sIgE-Dp were measured at baseline and 15 min and 1 h after a positive NAPT-Dp. Two allergic rhinitis (AR) patients were used as positive controls.

RESULTS

Fifty-four NAR children (61.1% boys) with the mean ± SD age of 11.1 ± 2.1 years were enrolled. The median duration of disease was 6.3 years. The most frequent comorbidity was asthma (38.9%). Eighty-seven percent of patients had mild persistent severity. NAPT-Dp was positive in 2/54 (3.7%) of NAR children who had increased symptom score and decreased minimal cross-sectional area (MCA) on ARM as well as PNIF. However, there was no change in the nasal tryptase and sIgE-Dp. The control AR patients had positive NAPT-Dp and increased nasal tryptase at 15 min without the change of sIgE-Dp.

CONCLUSION

LAR is an uncommon condition in children. Further investigation in a large population of children with NAR is needed.

The effectiveness of oxymetazoline plus intranasal steroid in the treatment of chronic rhinitis: A randomised controlled trial

BACKGROUND

The recommended drug for moderate to severe chronic rhinitis is intranasal steroids (INS). However, nasal congestion could be refractory and need additional treatments.

OBJECTIVE

We sought to explore the benefit of oxymetazoline (Oxymet) plus INS on nasal congestion without inducing rhinitis medicamentosa.

METHODS

We performed a 60-week, randomised, double-blind clinical trial in 50 patients, 18 years of age or greater, with chronic rhinitis who had used INS and cetirizine and still had nasal congestion. Subjects were randomised to receive 2 sprays of 0.05% Oxymet in each nostril twice daily or placebo for 4 weeks. All patients received 2 sprays of budesonide (100 μg/spray) in each nostril twice daily and 10 mg cetirizine once daily from entry throughout the study. Nasal symptom scores, nasal peak inspiratory flow (NPIF) and Rhinoconjunctivitis Quality of Life (Rcq) scores were measured.

RESULTS

Oxymet significantly reduced nasal congestion in subjects with chronic rhinitis compared with placebo on the day of 15-28 and 29-42. In subjects with allergic rhinitis, nasal congestion scores in the Oxymet group were significantly reduced compared with those in the placebo group on days 4-7, days 8-14, days 15-28 and days 29-42. In the Oxymet group, post hoc analysis showed that subjects with allergic rhinitis significantly improved their nasal congestion scores compared to non-allergic individuals (N, allergic/non-allergic = 18/7, p < 0.05). The combination of INS and Oxymet was not associated with rhinitis medicamentosa.

CONCLUSIONS

The combination of INS and Oxymet provides additional benefit compared to INS monotherapy in relieving nasal congestion in subjects with chronic rhinitis and allergic rhinitis without developing rhinitis medicamentosa.

Treatment of allergic rhinitis and urticaria: a review of the newest antihistamine drug bilastine

Allergic rhinitis and urticaria are common allergic diseases that may have a major negative impact on patients' quality of life. Bilastine, a novel new-generation antihistamine that is highly selective for the H1 histamine receptor, has a rapid onset and prolonged duration of action. This agent does not interact with the cytochrome P450 system and does not undergo significant metabolism in humans, suggesting that it has very low potential for drug-drug interactions, and does not require dose adjustment in renal impairment. As bilastine is not metabolized and is excreted largely unchanged, hepatic impairment is not expected to increase systemic exposure above the drug's safety margin. Bilastine has demonstrated similar efficacy to cetirizine and desloratadine in patients with seasonal allergic rhinitis and, in a Vienna Chamber study, a potentially longer duration of action than fexofenadine in patients with asymptomatic seasonal allergic rhinitis. It has also shown significant efficacy (similar to that of cetirizine) and safety in the long-term treatment of perennial allergic rhinitis. Bilastine showed similar efficacy to levocetirizine in patients with chronic spontaneous urticaria and can be safely used at doses of up to fourfold higher than standard dosage (80 mg once daily). The fourfold higher than standard dose is specified as an acceptable second-line treatment option for urticaria in international guidelines. Bilastine is generally well tolerated, both at standard and at supratherapeutic doses, appears to have less sedative potential than other second-generation antihistamines, and has no cardiotoxicity. Based on its pharmacokinetic properties, efficacy, and tolerability profile, bilastine will be valuable in the management of allergic rhinitis and urticaria.

The correlation between intradermal testing and serum specific IgE to house dust mite in negative skin prick test allergic rhinitis adult patients

BACKGROUND

Diagnosis of allergic rhinitis (AR) is based on history, physical examination, and skin prick test (SPT) while intradermal (ID) test can be performed to confirm the diagnosis in case of negative result of SPT. However, the ID test is not recommended for cat and timothy grass allergy because of its high false positive rate. As a result, the "quantitative" technique of serum specific IgE (sIgE) measurement might be helpful to diagnose AR with more confidence.

OBJECTIVES

To evaluate the correlation between ID tests and sIgE in the diagnosis of house dust mite (HDM)-sensitive AR patients.

METHODS

Patients with chronic rhinitis (CR) were recruited and SPT was performed. If SPT was negative, ID test and sIgE to HDM [Dermatophagoides pteronyssinus (Dp)] measurement were performed.

RESULTS

Eighty-two patients with chronic rhinitis (CR), whose SPTs were negative for Dp, were included. There were 39 males (47.6%) and 43 females (52.4%) aged between 18 and 76 years old (mean age = 43.3 years). The ID test was positive in 13 patients (15.9%), and was negative in 69 patients (84.1 %). sIgE to HDM was positive ( ≥ 0.35 kUA/l) in 2 patients (2.4%). There was a fair to moderate correlation between the size of wheal of ID test and sIgE to HDM (r = 0.44, 95% confidence interval: 0.19 to 0.67, p < 0.01).

CONCLUSION

ID test has a fair to moderate correlation with sIgE Dermatophagoides pteronyssinus and it can be used in CR patients with negative SPT where sIgE is not feasible.

A Surveillance Bacteriological Study of Acute Bacterial Rhinosinusitis in Thailand and the Clinical Responses to the Culture-directed Antibiotics

OBJECTIVE

To examine: 1) types of bacteria and antimicrobial sensitivity of commonly used antibiotics for acute bacterial rhinosinusitis (ABRS) in Thailand, 2) the effectiveness of using antibiotics according to antimicrobial sensitivity, and 3) the effectiveness of using antibiotics according to the Thai clinical practice guidelines (CPG) of ABRS.

MATERIAL AND METHOD

Descriptive & experimental studies were conducted in seven tertiary hospitals in Thailand. The specimens from maxillary sinuses were taken for bacterial cultures either by maxillary sinus tap or endoscopically directed middle meatus swabs in patients with clinically diagnosed ABRS. Antimicrobial sensitivity was performed and antibiotics were prescribed according to the results of antimicrobial sensitivity or the Thai CPG of ABRS.

RESULTS

A total of 113 patients were enrolled between August 2006 and April 2007, 104 cases of which were performed for bacteriological study. The incidence of bacterial growth was 60.6% (95% CI 51.0-69.4%). The most common bacteria was H. influenzae (25.0%, 95% CI 16.9-35.3%), followed by S. pneumoniae (14.3%, 95% CI 8.2-23.5%) and S. aureus (9.5%, 95% CI 4.7-17.9%), respectively, whilst M. catarrhalis was found only in 2.4% (95% CI 0.5-7.3%). Eight in 12 S. pneumoniae isolates were tested for the minimal inhibitory concentration of penicillin and found to be penicillin resistant strain in five specimens. Beta-lactamase producing H. influenzae was found in eight out of 20 isolates. H. influenzae had a tendency to be sensitive to amoxicillin/clavulanate, cefuroxime, cefpodoxime, azithromycin, clarithromycin, ofloxacin, levofloxacin and gatifloxacin, whilst S. pneumoniae had a tendency to be sensitive to amoxicillin/clavulanate, cefaclor ampicillin/sulbactam, cefuroxime, ofloxacin, levofloxacin, gatifloxacin, cefpodoxime, cefixime and cefdinir. The effectiveness of antibiotics prescription according to the Thai CPG of ABRS and antimicrobial sensitivity were comparable, 88.5% (95% CI 69.8-97.6%) and 82.2% (95% CI 67.9-92%), respectively.

CONCLUSION

H. influenzae is found to be the most common bacteria in Thai ABRS, followed by S. pneumoniae and S. aureus. There is a high incidence of beta-lactamase producing H. influenzae and penicillin non-susceptible S. pneumoniae.

Measuring outcomes in rhinosinusitis

BACKGROUND

Rhinosinusitis (RS) is a complex group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses.

METHODS

One of the problems with evaluating and treating RS is that there are often difficulties and controversies related to the means of diagnosis, which would prompt appropriate treatment.

RESULTS

This is particularly true in chronic RS where multiple treatments may be chosen and often these decisions are somewhat empiric and are based on the associated history, symptoms, and prior treatment. This also creates problems with assessing response to treatment where there are multiple tools that are used to diagnose RS and to assess response to both treatment and nontreatment over time. Consistent and reproducible measures of outcome may be lacking.

CONCLUSION

The purpose of this study was to describe the various diagnostic criteria that are used to evaluate RS and their role in measuring outcomes.

Combined radiofrequency volumetric tissue reduction and lateral outfracture of hypertrophic inferior turbinate in the treatment of chronic rhinitis: short-term and long-term outcome

BACKGROUND

Radiofrequency volumetric tissue reduction (RFVTR) of hypertrophic inferior turbinate (IT) is an effective way to treat patients with intractable nasal mucosal obstruction. We evaluated the effectiveness of combined RFVTR and lateral outfracture (LO) of hypertrophic IT in chronic rhinitis (CR) patients on reduction of nasal obstruction, rhinorrhea, and nasal pruritus both short and long term.

METHODS

Seventy-three patients with CR who failed medical treatment were recruited to undergo combined RFVTR and LO of hypertrophic IT. Nasal congestion scores were recorded before the operation, and immediately, 2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years, and 3 years after the operation. Rhinorrhea and pruritic score as well as total nasal airway resistance (TNAR) and total nasal airflow (TNAF) (measured by active anterior rhinomanometry) were recorded before the operation, and 2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years, and 3 years after the operation.

RESULTS

Forty-five patients completed the follow-up period of 3 years. Subjects consisted of 25 male and 20 female patients, with an average age of 31 years. Nasal congestion scores were significantly improved immediately after the operation. Nasal congestion scores and TNAR values were significantly decreased whereas TNAF values were significantly increased at every time point postoperatively. Rhinorrhea and pruritic scores were also significantly improved at every time point after 2 weeks postoperatively.

CONCLUSION

Combined RFVTR and LO of hypertrophic IT is an effective treatment for nasal obstruction, rhinorrhea, and nasal pruritus in CR and the result lasts up to 3 years postoperatively.

Inflammatory patterns in upper airway disease in the same geographical area may change over time

BACKGROUND

Inflammatory patterns of nasal polyps (NPs) may vary. Changes over time have not been investigated so far. This study was designed to evaluate the inflammatory patterns of NPs in Thailand at two time points 12 years apart, explore differences in Staphylococcus aureus (SA) mucosal carriage rates over time, and the latter's relationship with the inflammatory patterns.

METHODS

Formalin-fixed nasal tissue was obtained from 89 (47 in 1999 and 42 in 2011) patients suffering from chronic rhinosinusitis with NPs (CRSwNPs). Tissues were evaluated for eosinophils, neutrophils, IgE(+) cells, IgE and macrophage mannose receptors, interleukin (IL)-5 and IL-17 cytokine profile, and the presence of SA, using automated immunohistochemistry and peptide nucleic acid-fluorescence in situ hybridization.

RESULTS

We found a significant increase in the absolute values of eosinophils and IgE(+) cells in the 2011 CRSwNP tissue series compared with 1999 and a significant but smaller increase in neutrophils. Semiquantitative evaluation revealed significantly higher mean values of positive cells for all studied inflammatory markers in the 2011 group of patients, except for the high-affinity IgE receptor. This "eosinophilic shift" of inflammation was accompanied by higher SA carriage, as well as higher frequencies of SA invasion (54.8% versus 10.6%; p < 0.001) in the 2011 compared with 1999 subjects. Patients with asthma were more likely to have higher SA carriage rates compared with nonasthmatic patients.

CONCLUSION

There was a shift from predominantly neutrophilic to eosinophilic CRSwNPs in Thai patients within 12 years, with an increase in various inflammatory markers including IgE, which is associated with an increase in intramucosal presence of SA.

Staphylococcus aureus superantigens and their role in eosinophilic nasal polyp disease

Nasal polyposis is a chronic disease of the upper airways which adversely affects the quality of life of patients. Its pathophysiology is still unclear. Recently, several studies have shown different inflammatory pathways which relate to both innate and adaptive immune responses. Moreover, different phenotypes may exist in different ethnic groups of patients. This article will review recent data regarding the type of inflammation, cytokine profiles, involvement of macrophages and dendritic cells, and the impact of various organisms (especially Staphylococcus aureus and its superantigens) and their association with lower airway disease (especially asthma).

A randomized, prospective, double-blind study of the efficacy of dexpanthenol nasal spray on the postoperative treatment of patients with chronic rhinosinusitis after endoscopic sinus surgery

OBJECTIVE

To assess the efficacy of dexpanthenol nasal spray compared with normal saline spray in the postoperative treatment of patients with chronic rhinosinusitis (CRS) who underwent endoscopic sinus surgery (ESS).

MATERIALS AND METHOD

A prospective, randomized controlled study was conducted in CRS patients who underwent ESS. The enrolled patients had never been operated intranasally. These patients received either dexpanthenol or normal saline nasal spray intranasally four times a day for six weeks post-operatively.

RESULTS

Fifty CRS patients were recruited in the present study. Age ranged from 23 to 63 years (means 43.4 +/- 11.2 years). Forty-four percent of patients were diagnosed as CRS without nasal polyps (NP) (CRSs NP) and 56% were CRS with NP (CRSw NP). Twenty-five cases were randomly assigned to use dexpanthenol nasal spray whereas the other 25 cases used normal saline nasal spray. The preoperative severity of CRS, determined by the computerized tomography (CT) scan scoring system of Lund-McKay was 13.9 +/- 6.2 in the dexpanthenol group and 13.6 +/- 6.9 in the normal saline group, which were not statistically different (p > 0.05). The endoscopic scoring was 10.2 +/- 2 in the dexpanthenol group and 10.7 +/- 3 in the normal saline group, which were not statistically different (p > 0.05). The mucociliary transit time improvement (time difference between pre- and post-treatment by nasal spray) was 8.4 +/- 3.3 minutes in the dexpanthenol group and 1.7 +/- 1.2 minutes in the normal saline group, which were statistically different (p < 0.05).

CONCLUSION

The majority of the postoperative symptom scores and all of the endoscopic scores of the dexpanthenol group were not statistically different from those of the normal saline group. However, dexpanthenol nasal spray has superior efficacy compared with normal saline nasal spray on improvement of mucociliary clearance and nasal discharge in the postoperative care of CRS patients after ESS.

Airway allergy and viral infection

There are complex interactions between airway allergy and viral infection. Available evidence suggests that viral respiratory infection can initiate, maintain and activate exacerbation of allergic conditions in respiratory tract. Innate and inflammatory responses to acute viral infection play important roles in its relationship to allergic reactions. On the other hand, biased immune responses toward Th2 caused by an allergic reaction may make the immune response ineffective in combating viral infection. It was previously shown that allergy can increase the expression level of rhinovirus receptors on mucosal epithelial cells. This suggests that airway allergy may increase the risk of rhinovirus infection. We have recently shown that allergy may also increase the expression level of influenza virus receptors. This suggests that airway allergy and viral infection may have a reciprocal interaction. The effect of allergy on the risk and outcome of viral infection needs to be further confirmed in clinical studies and its potential implication for clinical practice should be considered.

Quantification of Der f 1 in houses of patients allergic to house dust mite, Dermatophagoides farinae, using a locally produced detection reagents

BACKGROUND

House dust mite (HDM) allergen quantification in house dust samples before and after the allergen elimination is one means of convincing the target population about the health benefits of allergen removal from their environment.

OBJECTIVE

To produce local reagents for quantification of Der f 1 (major allergen of Dermatophagoides farinae) in dust samples from houses of HDM allergic Thai patients.

METHODS

Recombinant Der f 1 was used for immunization of a BALB/c mouse for hybridoma production. Polyclonal antibody (PAb) to whole body extract of D. farinae was prepared from an immunized rabbit. A sandwich ELISA (MAb-allergen-PAb) was used, in comparison with the commercialized reagents (Indoor Biotechnology, UK), to quantify Der f 1 in dust samples.

RESULTS

Two hybridoma clones, Dfl-1 and Dfl-2, were established. Their secreted MAbs (MAbDfl-1 and MAbDfl-2, respectively) bound to the homologous antigen as well as native Der f 1 and a crude extract of D. farinae. Epitopes of MAbDfI-1 and MAbDfl-2 were located at amino acid residues 206NSQHYGISNYCQ217 and 283DYW---NSWD-WGDSG298 of Der f 1. MAbDf-1 had higher affinity to Der f 1 than the MAbDfl-2. A sandwich ELISA (MAbDfl-1-allergen-PAb) and commercialized reagents (MAbl-allergen-MAb2 sandwich ELISA) were used in comparison for quantification of Der f 1 in 42 dust samples collected from bedrooms and living rooms of 21 houses of the HDM allergic patients. All of the 42 dust samples measured by both ELISAs had the Der f 1 levels higher than 2 mg per gram of fine dust which is the HDM allergy sensitizing level. In addition, Der f 1 levels in 41 samples (except 1 sample from a living room) measured by the MAbDfI-1-PAb and MAbl-MAb2 sandwich ELISAs were higher than 10 mg per g of dust which is the morbidity level of HDM allergen. The local sandwich ELISA showed a high coefficient correlation (r = 0.91) in measuring known amounts of recombinant and native Der f 1. The results indicate that the reagents produced in the present study can be used for measuring the environmental levels of HDM Der f 1. The assay can also be used for standardization of the HDM extract for monitoring patient's allergenic status or for immunotherapeutic purpose.

In-vivo allergenic potency of Siriraj Mite Allergen Vaccine (SMAV) comparing with standardized vaccine in mite-sensitive patients

BACKGROUND

The prevalence of allergic diseases, particularly asthma and allergic rhinitis, has increased tremendously in Thailand and worldwide. House dust mite (HDM) is the major IgE sensitizer among allergic children and adults. We have developed local standardized mite allergen extracts, Siriraj Mite Allergen Vaccine (SMAV) from Dermatophagoides pteronyssinus (Dp) and Dermatophagoides farinae (Df) from our source materials which were highly purified (99%).

OBJECTIVE

To compare in-vivo allergenic potency of both SMAV Dp and Df with commercial standardized mite allergen vaccine by using skin prick testing in mite-sensitive individuals.

METHODS

This was a double-blind, randomized, self controlled study comparing SMAV and commercial standardized mite allergen vaccine (Dp and Df) by using skin prick testing in mite-sensitive adult volunteers, 18-60 years of age.

RESULTS

The study was performed in 54 adult volunteers (19 males, mean age 26.6 +/- 5.5 years old) who had positive skin test to commercial Dp and Df. Seventeen of them had no allergic disease. The most common allergic disease among the volunteers was allergic rhinitis (21/37). Mean wheal diameter of SMAV Dp and commercial Dp at the concentration of 10,000 and 5,000 AU/ml were equivalent but at the concentration of 2,500 AU/ml was inequivalent. Mean wheal diameter of SMAV Dp was significantly larger than commercial Dp at concentration of 2,500 AU/ml (p < 0.05). Mean wheal diameter of SMAV Df and commercial Df at all .3 concentrations were equivalent. There was no systemic side effect in all subjects.

CONCLUSION

The study demonstrated that in mite-sensitive adults, SPT using SMAV Dp (10,000 AU) and Df (10,000 AU) had equivalent allergenic potency to the commercial comparator without any systemic side effect.

Nasal provocation test: how to maximize its clinical use?

In order to diagnose allergic rhinitis (AR), skin prick tests and serum specific IgE level are the most common used methods. But there are some conditions which the results of both methods do not correlate with the clinical presentation of AR. Nasal provocation test is the method of detecting local IgE at the shock organ. There are some variations of NPT in terms of dosage, allergen administration, evaluation and scoring system. This article summarized the usefulness of NPT, its indication and contraindication, dosage and instillation techniques for allergens and evaluation of outcome in the hope that if we can standardize the procedure and make it easier to perform, NPT will be applied more in clinical practice. In addition normal values among Asian ethnics are presented for appropriate interpretation of the test.

Efficacy and Safety of Once Daily Fluticasone Furoate Nasal Spray for Treatment of Irritant (Non-allergic) Rhinitis

INTRODUCTION

The safety and efficacy of fluticasone furoate nasal spray (FFNS) for the symptoms of seasonal and perennial allergic rhinitis have been previously demonstrated in several clinical studies. The objective of this pilot study was to compare the efficacy and safety of FFNS 110 mcg once daily with placebo in patients with irritant (non-allergic) rhinitis triggered predominantly by air pollution.

METHODS

This was a randomized, double-blind, placebo-controlled, 4-week study of subjects in Thailand with irritant rhinitis who received either FFNS 110 mcg (N=53) or placebo (N=49) once-daily. Subjects with a ≥2 year history of air pollution as their predominant rhinitis trigger, negative skin test to local seasonal/perennial allergens, positive histamine skin test, and normal sinus radiograph were enrolled if they met minimum reflective total nasal symptom score (rTNSS) ≥4.5 (maximum=9) and a nasal congestion score of ≥2 (maximum =3). All were assessed for nasal eosinophilia at study entry and completion. Air quality was monitored throughout the study. The primary efficacy endpoint was the mean change from baseline over the treatment period in daily rTNSS, the average of the morning and evening rTNSS. The key secondary measure was the mean change from baseline over the entire treatment period in morning pre-dose instantaneous total nasal symptom score (iTNSS).

RESULTS

The Air Quality Index (AQI) during the study generally did not reach unhealthy levels. Baseline daily rTNSS scores were similar between treatment groups (FFNS=6.7; placebo=6.4). The least square mean change from baseline in rTNSS was -2.17 and -2.10 for FFNS and placebo, respectively, with a difference of -0.065 (p=0.845). Gradual improvements were seen in both treatment groups for iTNSS; however, the treatment difference (-0.075) was not statistically significant (p=0.827). Additionally, there were no statistically significant differences between treatment groups for AM and PM rTNSS, individual nasal symptoms, daily reflective, AM and PM reflective and AM pre-dose instantaneous total ocular symptom scores (TOSS) or individual ocular symptom scores. Nasal cytology at baseline found more than two-thirds of subjects had <20% eosinophils. Adverse events were few and similar between groups and noted as mild in intensity.

CONCLUSION

Subjects receiving FFNS had similar improvement to placebo in their rhinitis symptoms. The lack of a treatment effect may be in part due to the overall good air quality present throughout the study or an insufficient dose or duration of FFNS. The safety findings showed FFNS 110 mcg once daily to be well tolerated.

Enhanced susceptibility of nasal polyp tissues to avian and human influenza viruses

BACKGROUND

Influenza viruses bind and infect respiratory epithelial cells through sialic acid on cell surface. Differential preference to sialic acid types contributes to host- and tissue-tropism of avian and seasonal influenza viruses. Although the highly pathogenic avian influenza virus H5N1 can infect and cause severe diseases in humans, it is not efficient in infecting human upper respiratory tract. This is because of the scarcity of its receptor, α2,3-linked sialic acid, in human upper airway. Expression of sialic acid can be influenced by various factors including inflammatory process. Allergic rhinitis and nasal polyp are common inflammatory conditions of nasal mucosa and may affect expression of the sialic acid and susceptibility to influenza infection.

METHODOLOGY/PRINCIPAL FINDING

To test this hypothesis, we detected α2,3- and α2,6-linked sialic acid in human nasal polyp and normal nasal mucosal tissues by lectin staining and infected explants of those tissues with avian influenza viruses H5N1 and seasonal influenza viruses. We show here that mucosal surface of nasal polyp expressed higher level of α2,3- and α2,6-linked sialic acid than normal nasal mucosa. Accordingly, both H5N1 avian influenza viruses and seasonal influenza viruses replicated more efficiently in nasal polyp tissues explants.

CONCLUSIONS/SIGNIFICANCE

Our data suggest a role of nasal inflammatory conditions in susceptibility to influenza infection, especially by avian influenza viruses, which is generally inefficient in infecting human upper airway. The increased receptor expression may contribute to increased susceptibility in some individuals. This may contribute to the gradual adaptation of the virus to human population.

Superantigens

Superantigens (SAgs) are derived from diverse sources, including bacteria, viruses, and human hepatic tissue. SAgs initially cause lymphocyte activation but then result in clonal deletion and anergy, leading to immune tolerance. They can also act as superallergens by stimulating a broad spectrum of mast cells and basophils in patients with allergic conditions. The newly described staphylococcal SAg-like proteins subvert innate immune function by several mechanisms, which are distinct from SAgs' effects on lymphocytes and other acquired immune processes. There is mounting evidence to suggest that SAgs play a role in the pathophysiology of inflammatory airway disease. The pathophysiologic role of SAg-like proteins awaits clarification.

Quality of life in patients with chronic rhinitis after radiofrequency inferior turbinate reduction

OBJECTIVE

This prospective, before-and-after study was aimed to demonstrate the effectiveness of radiofrequency (RF) inferior turbinate reduction in patients with chronic rhinitis refractory to medication on quality of life.

MATERIAL AND METHOD

From April 2007 to April 2008, there were 28 patients enrolled in the present study. The temperature-controlled radiofrequency (RF) was applied at inferior turbinate on both sides. To compare before and at the 8th weeks after RF treatment, the patients were given Rhinoconjuctivitis Quality of Life questionnaires (Rcq-36) and questionnaires using visual analog scales (0-10) to assess subjective symptoms such as the frequency and severity of nasal obstruction, nasal discharge, hyposmia, and sneezing. The acoustic rhinometry and active rhinomanometry were also done to evaluate objective outcomes.

RESULTS

At the 8th week after RF treatment, the patients quality of life in every dimension of Rcq-36 and all symptoms revealed a significant improvement (p < 0.05). Particularly, the severity and frequency of nasal congestion were reduced from 6.8 +/- 2.5 and 6.3 +/- 2.5 to 2.6 +/- 2.2 and 2.5 +/- 2.1 respectively (p < 0.001). However, there was no statistically significant change in objective findings. All patients reported only minimal pain and no complication.

CONCLUSION

This is the first study to show that radiofrequency inferior turbinate reduction can improve quality ofhlife ofthe patients with chronic rhinitis in all dimensions. It is a simple and minimal invasive procedure, and thus will be a good alternative treatment.

Smell disorders: a study of 132 patients from the first Smell and Taste Clinic of Thailand

OBJECTIVE

To investigate types and possible causes of smell disorders in patients who attended the Smell and Taste Clinic, Siriraj Hospital.

MATERIAL AND METHOD

Medical records of patients with smell disorders who attended the Smell and Taste Clinic, Siriraj Hospital between July 2002 and August 2005 were reviewed for gender age, duration of complaint, severity (hyposmia or anosmia), and previous medical illnesses (e.g., upper respiratory tract infection (URI), head injury, sinonasal problems, etc). All patients had complete physical examination, nasal endoscopy, and phenyl ethyl alcohol (PEA) olfactory threshold test.

RESULTS

One hundred and eighty eight patients' medical records were reviewed. Smell disorders were confirmed in 132 cases (male=58, female=74). Nearly an equal number of anosmia and hyposmia cases were found (50.8% and 49.2% respectively). Possible causes of smell disorders were categorized as follows: sinonasal disease (SND) (66.7%), head injury (12.1%), idiopathic cause (10.6%), URI (6.8%), congenital cause (3%), and others (0.8%). SND was the most common cause of smell disorders despite different age groups and duration of smell disorders. PEA test scores were higher in head injury and idiopathic groups compared with those in SND and post URI groups.

CONCLUSION

The present data showed that SND was the major cause of smell disorders in every age group and in each duration group followed by head injury, idiopathic cause, and URI respectively. Therefore, nasal endoscopy is highly recommended for every patient with smell disorders.