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Gray NJ, Redshaw EL, Isaacs D, Tarzi MD, Smith HE, Frew AJ. Allergy in the elderly: A case note review of referrals to an adult allergy clinic. Clin Exp Allergy 2018; 48:1238-1241. [DOI: 10.1111/cea.13179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 03/22/2018] [Accepted: 04/04/2018] [Indexed: 12/13/2022]
Affiliation(s)
- N. J. Gray
- Department of Allergy & Respiratory Medicine; Royal Sussex County Hospital; Brighton UK
| | - E. L. Redshaw
- Department of Primary Care and Public Health; Brighton & Sussex Medical School; Brighton UK
| | - D. Isaacs
- Department of Primary Care and Public Health; Brighton & Sussex Medical School; Brighton UK
| | - M. D. Tarzi
- Department of Allergy & Respiratory Medicine; Royal Sussex County Hospital; Brighton UK
| | - H. E. Smith
- Department of Primary Care and Public Health; Brighton & Sussex Medical School; Brighton UK
- Family Medicine and Primary Care; Lee Kong Chian School of Medicine; Nanyang Technological University Singapore; Singapore 308232
| | - A. J. Frew
- Department of Allergy & Respiratory Medicine; Royal Sussex County Hospital; Brighton UK
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Qureshi NR, Rintoul RC, Miles KA, George S, Harris S, Madden J, Cozens K, Little LA, Eichhorst K, Jones J, Moate P, McClement C, Pike L, Sinclair D, Wong WL, Shekhdar J, Eaton R, Shah A, Brindle L, Peebles C, Banerjee A, Dizdarevic S, Han S, Poon FW, Groves AM, Kurban L, Frew AJ, Callister ME, Crosbie P, Gleeson FV, Karunasaagarar K, Kankam O, Gilbert FJ. Accuracy and cost-effectiveness of dynamic contrast-enhanced CT in the characterisation of solitary pulmonary nodules-the SPUtNIk study. BMJ Open Respir Res 2016; 3:e000156. [PMID: 27843550 PMCID: PMC5073572 DOI: 10.1136/bmjresp-2016-000156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 08/17/2016] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Solitary pulmonary nodules (SPNs) are common on CT. The most cost-effective investigation algorithm is still to be determined. Dynamic contrast-enhanced CT (DCE-CT) is an established diagnostic test not widely available in the UK currently. METHODS AND ANALYSIS The SPUtNIk study will assess the diagnostic accuracy, clinical utility and cost-effectiveness of DCE-CT, alongside the current CT and 18-flurodeoxyglucose-positron emission tomography) (18FDG-PET)-CT nodule characterisation strategies in the National Health Service (NHS). Image acquisition and data analysis for 18FDG-PET-CT and DCE-CT will follow a standardised protocol with central review of 10% to ensure quality assurance. Decision analytic modelling will assess the likely costs and health outcomes resulting from incorporation of DCE-CT into management strategies for patients with SPNs. ETHICS AND DISSEMINATION Approval has been granted by the South West Research Ethics Committee. Ethics reference number 12/SW/0206. The results of the trial will be presented at national and international meetings and published in an Health Technology Assessment (HTA) Monograph and in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN30784948; Pre-results.
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Affiliation(s)
- N R Qureshi
- Department of Radiology , Papworth Hospital , Cambridge , UK
| | - R C Rintoul
- Department of Thoracic Oncology , Papworth Hospital , Cambridge , UK
| | - K A Miles
- Institute of Nuclear Medicine, University College London , London , UK
| | - S George
- Public Health Sciences and Medical Statistics, University of Southampton , Southampton , UK
| | - S Harris
- Public Health Sciences and Medical Statistics, University of Southampton , Southampton , UK
| | - J Madden
- Southampton Clinical Trials Unit , University of Southampton , Southampton , UK
| | - K Cozens
- Southampton Clinical Trials Unit , University of Southampton , Southampton , UK
| | - L A Little
- Southampton Clinical Trials Unit , University of Southampton , Southampton , UK
| | - K Eichhorst
- Southampton Clinical Trials Unit , University of Southampton , Southampton , UK
| | - J Jones
- Centre for Innovation and Leadership in Health Sciences, University of Southampton, UK
| | - P Moate
- Southampton Clinical Trials Unit , University of Southampton , Southampton , UK
| | - C McClement
- Southampton Clinical Trials Unit , University of Southampton , Southampton , UK
| | - L Pike
- Division of Imaging Sciences and Biomedical Engineering , King's College London , London , UK
| | - D Sinclair
- Division of Imaging Sciences and Biomedical Engineering , King's College London , London , UK
| | - W L Wong
- Department of Medical Physics , Paul Strickland Scanner Centre, Mount Vernon Hospital, East and North Herts NHS Trust , Stevenage , UK
| | - J Shekhdar
- Radiation Protection Department, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - R Eaton
- Radiation Protection Department, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - A Shah
- Radiation Protection Department, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - L Brindle
- Faculty of Health Sciences , University of Southampton , Southampton , UK
| | - C Peebles
- Department of Radiology and Respiratory Medicine , Southampton University Hospitals NHS Foundation Trust , Southampton , UK
| | - A Banerjee
- Department of Radiology and Respiratory Medicine , Southampton University Hospitals NHS Foundation Trust , Southampton , UK
| | - S Dizdarevic
- Departments of Respiratory and Nuclear Medicine , Brighton and Sussex University Hospitals NHS Trust , Brighton , UK
| | - S Han
- West of Scotland PET Centre, Gartnavel Hospital , Glasgow , UK
| | - F W Poon
- West of Scotland PET Centre, Gartnavel Hospital , Glasgow , UK
| | - A M Groves
- Institute of Nuclear Medicine, University College London , London , UK
| | - L Kurban
- Department of Radiology , Aberdeen Royal Hospitals NHS Trust , Aberdeen , UK
| | - A J Frew
- Departments of Respiratory and Nuclear Medicine , Brighton and Sussex University Hospitals NHS Trust , Brighton , UK
| | - M E Callister
- Department of Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - P Crosbie
- North West Lung Centre, University Hospital of South Manchester, Manchester, UK
| | - F V Gleeson
- Department of Radiology , Churchill Hospital and University of Oxford , Oxford , UK
| | - K Karunasaagarar
- Department of Radiology , Worcestershire Royal Hospital , Worcester , UK
| | - O Kankam
- Department of Thoracic Medicine , East Sussex Hospitals NHS Trust , Saint Leonards-on-Sea , UK
| | - F J Gilbert
- Department of Radiology , University of Cambridge School of Clinical Medicine, Biomedical research centre, University of Cambridge , Cambridge , UK
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Smith HE, Wade J, Frew AJ. What proportion of adult allergy referrals to secondary care could be dealt with in primary care by a GP with special interest? Clin Transl Allergy 2016; 6:3. [PMID: 26807213 PMCID: PMC4722667 DOI: 10.1186/s13601-016-0091-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 12/08/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The concept of a General Practitioner with Special Interest (GPwSI) was first proposed in the 2000 National Health Service Plan, as a way of providing specialised treatment closer to the patient's home and reducing hospital waiting times. Given the patchy and inadequate provision of allergy services in the UK the introduction of GPwSIs might reduce the pressure on existing specialist services. OBJECTIVES This study assessed what proportion of referrals to a specialist allergy clinic could be managed in a GPwSI allergy service with a predefined range of facilities and expertise (accurate diagnosis and management of allergy; skin prick testing; provision of advice on allergen avoidance; ability to assess suitability for desensitisation). METHODS 100 consecutive GP referrals to a hospital allergy clinic were reviewed to determine whether patients could be seen in a community-based clinic led by a general practitioner with special interest (GPwSI) allergy. The documentation relating to each referral was independently assessed by three allergy specialists. The referrals were judged initially on the referral letter alone and then re-assessed with the benefit of information summarised in the clinic letter, to determine whether appropriate triage decisions could be made prospectively. The proportion of referrals suitable for a GPwSI was calculated and their referral characteristics identified. RESULTS 29 % referrals were judged unanimously appropriate for management by a GPwSI and an additional 30 % by 2 of the 3 reviewers. 18 % referrals were unsuitable for a GPwSI service because of the complexity of the presenting problem, patient co-morbidity or the need for specialist knowledge or facilities. CONCLUSIONS AND CLINICAL RELEVANCE At least a quarter, and possibly half, of allergy referrals to our hospital-based service could be dealt with in a GPwSI clinic, thereby diversifying the patient pathway, allowing specialist services to focus on more complex cases and reducing the waiting time for first appointments.
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Affiliation(s)
- H. E. Smith
- Division of Primary Care and Public Health, Brighton and Sussex Medical School, Room 319, Mayfield House, Falmer, Brighton, BN1 9PH UK
| | - J. Wade
- Division of Primary Care and Public Health, Brighton and Sussex Medical School, Room 319, Mayfield House, Falmer, Brighton, BN1 9PH UK
| | - A. J. Frew
- Department of Respiratory Medicine, Royal Sussex County Hospital, Brighton, UK
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Shamji MH, Ljørring C, Francis JN, Calderon MA, Larché M, Kimber I, Frew AJ, Ipsen H, Lund K, Würtzen PA, Durham SR. Functional rather than immunoreactive levels of IgG4 correlate closely with clinical response to grass pollen immunotherapy. Allergy 2012; 67:217-26. [PMID: 22077562 DOI: 10.1111/j.1398-9995.2011.02745.x] [Citation(s) in RCA: 216] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Induction of allergen-specific IgG(4) antibodies is the most consistent immunological finding in immunotherapy trials. However, quantitative assessments of IgG(4) antibodies have not proven beneficial in evaluating clinical changes during or after immunotherapy. In the current study, we investigated the relationship between clinical outcome and allergen-specific IgG(4) titres or functional antibody responses following immunotherapy. We hypothesized that functional assays of serum IgG-associated inhibitory activity such as inhibition of IgE-allergen interactions (IgE-blocking factor) and inhibition of CD23-dependent IgE-facilitated allergen binding (IgE-FAB) correlate more closely with clinical outcome and may be biomarkers of clinical response. METHODS In an 8-month dose-response randomized double-blind placebo-controlled study, 221 polysensitized subjects with severe seasonal rhinitis received Alutard SQ, Phleum pratense 100,000 SQ-U, 10,000 SQ-U or placebo injections. Serum specimens were collected before treatment, after up-dosing, during the peak season and at the end of the study. Allergen-specific IgG(4) titres and IgG-associated inhibitory activity were evaluated. RESULTS A time- and dose-dependent increase in serum inhibitory activity for both the IgE-blocking factor and IgE-FAB was observed, which paralleled increases in grass pollen-specific IgG(4) antibodies. A modest but significant inverse relationship was demonstrated between postimmunotherapy serum inhibitory activity and combined symptom-rescue medication scores (IgE-FAB: r = -0.25, P = 0.0002; IgE-blocking factor: r = -0.28, P < 0.0001), whereas this was not observed for immunoreactive IgG(4) levels (r = -0.11, P = 0.12). CONCLUSIONS Functional assays of inhibitory IgG(4) and IgE-blocking factor may be more useful surrogates of clinical response than IgG(4). Whether these antibody effects may serve as predictive biomarkers of clinical efficacy in individual patients requires further investigation.
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Affiliation(s)
- M H Shamji
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College London, UK
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Rashid RS, Smith KA, Nambiar KZ, Frew AJ, Tarzi MD. Pollen-food syndrome is related to Bet v 1/PR-10 protein sensitisation, but not all patients have spring rhinitis. Allergy 2011; 66:1391-2. [PMID: 21569050 DOI: 10.1111/j.1398-9995.2011.02618.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- R S Rashid
- Department of Immunology, Brighton and Sussex Medical School, University of Sussex, UK
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Krishna MT, Ewan PW, Diwakar L, Durham SR, Frew AJ, Leech SC, Nasser SM. Diagnosis and management of hymenoptera venom allergy: British Society for Allergy and Clinical Immunology (BSACI) guidelines. Clin Exp Allergy 2011; 41:1201-20. [DOI: 10.1111/j.1365-2222.2011.03788.x] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Walker SM, Durham SR, Till SJ, Roberts G, Corrigan CJ, Leech SC, Krishna MT, Rajakulasingham RK, Williams A, Chantrell J, Dixon L, Frew AJ, Nasser SM. Immunotherapy for allergic rhinitis. Clin Exp Allergy 2011; 41:1177-200. [DOI: 10.1111/j.1365-2222.2011.03794.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Bailey S, Albardiaz R, Frew AJ, Smith H. Restaurant staff's knowledge of anaphylaxis and dietary care of people with allergies. Clin Exp Allergy 2011; 41:713-7. [DOI: 10.1111/j.1365-2222.2011.03748.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Abstract
Measuring quality of life (QoL) has become an increasingly important dimension of assessing patient well-being and drug efficacy. As there are now several asthma QoL questionnaires to choose from, it is important to appreciate their strengths and weaknesses. To assist in this choice, we have reviewed the existing questionnaires in a structured way. Information relating to the conceptual and measurement model, reliability, validity, interpretability, burden, administration format and translations was extracted from the published literature. The instruments differ in almost all criteria considered, and therefore it cannot be assumed that they measure the same thing. We recommend the selection of questionnaires that are designed only for asthma and that do not assess symptoms as part of QoL. Only two of the questionnaires reviewed fulfill these requirements: the Sydney Asthma QoL Questionnaire (AQLQ-S) and the Living with Asthma Questionnaire (LWAQ). However, for multinational studies, it may be convenient or practical to use questionnaires that have been linguistically validated in many languages (AQLQ-J, SGRQ). It remains unclear which of these questionnaires best reflects patient perceptions of QoL. Our review did not involve patients, so for the time being choosing from existing questionnaires requires a compromise based on the rigor of the development process and the target patient group.
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Affiliation(s)
- C J Apfelbacher
- Division of Public Health and Primary Care, Brighton and Sussex Medical School, Falmer, UK.
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Abstract
Anaphylaxis is a systemic allergic reaction that often involves respiratory symptoms and cardiovascular collapse, which are potentially life-threatening if not treated promptly with intramuscular adrenaline. Owing to the unpredictable nature of anaphylaxis and accidental exposure to allergens (such as peanuts and shellfish), patients should be prescribed intramuscular adrenaline auto-injectors and carry these with them at all times. Patients also need to be able to use their auto-injectors correctly while under high stress, when an anaphylactic attack occurs. Despite this, an alarming number of patients fail to carry their auto-injectors and many patients, carers of children with known anaphylaxis and healthcare professionals do not know how to use the device correctly, despite having had training. Currently available auto-injector devices have various limitations that may impede their use in the management of anaphylaxis. There is also a lack of validated assessment criteria and regulatory requirements for new devices. This review describes the different delivery systems used in currently available auto-injectors and discusses the key barriers to the use of adrenaline auto-injectors, with the goal of identifying the 'ideal' features/characteristics of such devices in the emergency treatment of anaphylaxis that will ensure ease of use, portability and accurate delivery of a life-saving drug.
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Affiliation(s)
- A J Frew
- Department of Respiratory Medicine, Royal Sussex County Hospital, Brighton, UK
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Stenfors N, Bosson J, Helleday R, Behndig AF, Pourazar J, Törnqvist H, Kelly FJ, Frew AJ, Sandström T, Mudway IS, Blomberg A. Ozone exposure enhances mast-cell inflammation in asthmatic airways despite inhaled corticosteroid therapy. Inhal Toxicol 2010; 22:133-9. [PMID: 20044881 DOI: 10.3109/08958370903005736] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Asthmatics are recognised to be more susceptible than healthy individuals to adverse health effects caused by exposure to the common air pollutant ozone. Ozone has been reported to induce airway neutrophilia in mild asthmatics, but little is known about how it affects the airways of asthmatic subjects on inhaled corticosteroids. We hypothesised that ozone exposure would exacerbate the pre-existent asthmatic airway inflammation despite regular inhaled corticosteroid treatment. Therefore, we exposed subjects with persistent asthma on inhaled corticosteroid therapy to 0.2 ppm ozone or filtered air for 2 h, on 2 separate occasions. Lung function was evaluated before and immediately after exposure, while bronchoscopy was performed 18 h post exposure. Compared to filtered air, ozone exposure increased airway resistance. Ozone significantly enhanced neutrophil numbers and myeloperoxidase levels in airway lavages, and induced a fourfold increase in bronchial mucosal mast cell numbers. The present findings indicate that ozone worsened asthmatic airway inflammation and offer a possible biological explanation for the epidemiological findings of increased need for rescue medication and hospitalisation in asthmatic people following exposure to ambient ozone.
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Affiliation(s)
- N Stenfors
- Department of Public Health and Clinical Medicine, Respiratory Medicine, Umeå University, Umeå, Sweden.
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Diwakar L, Noorani S, Huissoon AP, Frew AJ, Krishna MT. Practice of venom immunotherapy in the United Kingdom: a national audit and review of literature. Clin Exp Allergy 2008; 38:1651-8. [PMID: 18727621 DOI: 10.1111/j.1365-2222.2008.03044.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Venom immunotherapy (VIT) is the only effective treatment for prevention of serious allergic reactions to bee and wasp stings in sensitized individuals. However, controversies exist relating to diagnosis, indications for treatment and treatment schedules. We audited current practice of VIT in the United Kingdom to evaluate adherence to international guidelines. METHODS An online questionnaire was sent to all clinicians practising immunotherapy identified on the British Society of Allergy and Clinical Immunology website. Eighty-six questionnaires were sent and 53 responses (61.6%) were received. Of these, 48 (85%) carried out VIT at their centre. RESULTS Skin prick tests (SPT) and serum venom-specific IgE (SSIgE) were equally preferred as first-line investigation. Fifty percent of the respondents perform intradermal tests if both SPT and SSIgE are negative. While 8% of respondents commence VIT in patients with negative SSIgE and a history of severe reaction, 57% prefer to repeat the tests in 6-12 months if serum tryptase is elevated. If the insect responsible is uncertain and SSIgE is detected against bee and wasp venoms, 22% of the respondents will desensitize to both while 32% initiate treatment against the venom with the higher SSIgE. A protocol of weekly up-dosing for 12 weeks is preferred for induction and only 25% of respondents have ever used rush or ultra-rush protocols. Three years is thought to be optimum duration of VIT by most (56%). Eleven percent perform sting challenges at the end of treatment. Although 47% measure SSIgE at the end of treatment, only 3% use these results as a basis for discontinuing VIT. CONCLUSION Currently there is considerable variation in the diagnosis and management of hymenoptera venom allergy in the United Kingdom. This audit has demonstrated that the current international guidelines for the diagnosis and management of hymenoptera venom allergy are not being followed by UK allergy practitioners.
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Affiliation(s)
- L Diwakar
- Department of Allergy and Immunology, Heartlands Hospital, Birmingham, UK.
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Simons FER, Frew AJ, Ansotegui IJ, Bochner BS, Golden DBK, Finkelman FD, Leung DYM, Lotvall J, Marone G, Metcalfe DD, Müller U, Rosenwasser LJ, Sampson HA, Schwartz LB, van Hage M, Walls AF. Practical allergy (PRACTALL) report: risk assessment in anaphylaxis. Allergy 2008; 63:35-7. [PMID: 18053014 DOI: 10.1111/j.1398-9995.2007.01605.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Effector mechanisms in anaphylaxis were reviewed. Current approaches to confirmation of the clinical diagnosis were discussed. Improved methods for distinguishing between allergen sensitization (which is common in the general population) and clinical risk of anaphylaxis (which is uncommon) were deliberated. Innovative techniques that will improve risk assessment in anaphylaxis in the future were described.
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Affiliation(s)
- F E R Simons
- Department of Pediatrics & Child Health, University of Manitoba, Winnipeg, MB, Canada
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Abstract
BACKGROUND Treatment of allergic rhinitis with subcutaneous allergen immunotherapy is effective in terms of reductions in symptoms and seasonal use of reliever medication. Its effect on quality of life (QoL), reflecting the impact of symptoms on work/school performance and leisure activities is, however, important and often overlooked. AIMS OF THE STUDY To assess effect on QoL of specific immunotherapy with two doses of Alutard SQ Phleum pratense in patients with moderately to severe seasonal allergic rhinoconjunctivitis inadequately controlled by standard drug therapy. METHODS Double-blind, randomized, placebo-controlled study of 410 patients with seasonal allergic rhinoconjunctivitis. Participants were randomized (2 : 1 : 1) to receive Alutard SQ P. pratense (ALK-Abelló) at maintenance doses of 100,000 SQ-U (203 subjects), 10,000 SQ-U (104 subjects) or placebo (103 subjects) given by subcutaneous injections. The groups were well matched for demographics and baseline symptoms. Quality of life was assessed using the Rhinoconjunctivitis Quality of Life Questionnaire which covers seven domains of health before and in the peak of the pollen season. RESULTS While all domain scores were significantly improved when comparing 100,000 SQ-U with placebo, two domain scores were significantly improved when comparing 10,000 SQ-U with placebo. When comparing 100,000 SQ-U with 10,000 SQ-U, four domain scores were significantly improved. CONCLUSION Treatment with Alutard SQ significantly improved the seasonal QoL of patients suffering from allergic rhinoconjunctivitis. The improvement was more pronounced and wider ranging in patients who received the higher 100,000 SQ-U maintenance dose.
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Affiliation(s)
- R J Powell
- Clinical Immunology Unit, University Hospital, Queens Medical Centre, Nottingham, UK
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Brown JL, Behndig AF, Sekerel BE, Pourazar J, Blomberg A, Kelly FJ, Sandström T, Frew AJ, Wilson SJ. Lower airways inflammation in allergic rhinitics: a comparison with asthmatics and normal controls. Clin Exp Allergy 2007; 37:688-95. [PMID: 17456216 DOI: 10.1111/j.1365-2222.2007.02695.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Allergic rhinitis (AR) and asthma represent a continuum of atopic disease. AR is believed to pre-dispose an individual to asthma. Compared with asthmatics and normal controls, the inflammatory response in the lower airways of rhinitics is not fully elucidated. To test the hypothesis that the inflammatory response in the airways of subjects with AR is at a level intermediate between that in normal controls and asthmatics, we have characterized bronchial inflammation and cytokine mRNA levels in non-asthmatic allergic rhinitics and compared it with subjects with allergic asthma and with normal controls. METHODS Endobronchial mucosal biopsies were obtained at bronchoscopy from 14 allergic rhinitics, 16 asthmatics and 21 normal controls. Biopsies were embedded into glycol methacrylate resin for immunohistochemical analysis of cellular inflammation and snap frozen for semi-quantitative PCR analysis of cytokine mRNA levels. RESULTS Airway inflammation in rhinitic subjects was characterized by an increase in submucosal eosinophils, mast cells and the mRNA expression of TNF-alpha, at an intermediate level between healthy and asthmatics. In addition, CD3(+) and CD8(+) lymphocytes in the epithelium, the endothelial expression of vascular adhesion molecule-1 and IL-1 beta mRNA were higher in the allergic rhinitics compared with both normal controls and asthmatics, whereas growth-related oncogene alpha-mRNA was decreased in AR compared with both healthy and asthmatics. Airway inflammation in the asthmatic group was characterized by higher numbers of eosinophils and mast cells, together with an increase in TNF-alpha-mRNA compared with both healthy and rhinitics. IFN-gamma mRNA was the highest in normal controls and lowest in the asthmatics. CONCLUSIONS In individuals with AR the present data suggest an intermediate state of airway inflammation between that observed in normal individuals and subjects with clinical asthma. It is also indicated that IFN-gamma production by CD8(+) T lymphocytes could be protective against the development of airway hyperresponsiveness. Further work is needed to evaluate this hypothesis.
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MESH Headings
- Adolescent
- Adult
- Asthma/complications
- Asthma/immunology
- Bronchitis/etiology
- Bronchitis/immunology
- Bronchoscopy
- Cytokines/biosynthesis
- Eosinophilia/etiology
- Female
- Forced Expiratory Volume
- Humans
- Immunoenzyme Techniques
- Male
- Mast Cells/pathology
- Polymerase Chain Reaction/methods
- Rhinitis/complications
- Rhinitis/immunology
- Rhinitis/physiopathology
- Rhinitis, Allergic, Perennial/complications
- Rhinitis, Allergic, Perennial/immunology
- Rhinitis, Allergic, Perennial/physiopathology
- Rhinitis, Allergic, Seasonal/complications
- Rhinitis, Allergic, Seasonal/immunology
- Rhinitis, Allergic, Seasonal/physiopathology
- Skin Tests
- T-Lymphocyte Subsets/immunology
- Vascular Cell Adhesion Molecule-1/metabolism
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Affiliation(s)
- J L Brown
- Allergy and Inflammation Research, University of Southampton, Southampton, UK
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Powell RJ, Frew AJ, Corrigan CJ, Durham SR. Effect of grass pollen immunotherapy with Alutard SQ on quality of life in seasonal allergic rhinoconjunctivitis. Allergy 2007. [PMID: 17714551 DOI: 10.1111/j.1398-9995.2007.01455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Treatment of allergic rhinitis with subcutaneous allergen immunotherapy is effective in terms of reductions in symptoms and seasonal use of reliever medication. Its effect on quality of life (QoL), reflecting the impact of symptoms on work/school performance and leisure activities is, however, important and often overlooked. AIMS OF THE STUDY To assess effect on QoL of specific immunotherapy with two doses of Alutard SQ Phleum pratense in patients with moderately to severe seasonal allergic rhinoconjunctivitis inadequately controlled by standard drug therapy. METHODS Double-blind, randomized, placebo-controlled study of 410 patients with seasonal allergic rhinoconjunctivitis. Participants were randomized (2 : 1 : 1) to receive Alutard SQ P. pratense (ALK-Abelló) at maintenance doses of 100,000 SQ-U (203 subjects), 10,000 SQ-U (104 subjects) or placebo (103 subjects) given by subcutaneous injections. The groups were well matched for demographics and baseline symptoms. Quality of life was assessed using the Rhinoconjunctivitis Quality of Life Questionnaire which covers seven domains of health before and in the peak of the pollen season. RESULTS While all domain scores were significantly improved when comparing 100,000 SQ-U with placebo, two domain scores were significantly improved when comparing 10,000 SQ-U with placebo. When comparing 100,000 SQ-U with 10,000 SQ-U, four domain scores were significantly improved. CONCLUSION Treatment with Alutard SQ significantly improved the seasonal QoL of patients suffering from allergic rhinoconjunctivitis. The improvement was more pronounced and wider ranging in patients who received the higher 100,000 SQ-U maintenance dose.
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Affiliation(s)
- R J Powell
- Clinical Immunology Unit, University Hospital, Queens Medical Centre, Nottingham, UK
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Lindemann RK, Newbold A, Whitecross KF, Cluse LA, Frew AJ, Ellis L, Williams S, Wiegmans AP, Dear AE, Scott CL, Pellegrini M, Wei A, Richon VM, Marks PA, Lowe SW, Smyth MJ, Johnstone RW. Analysis of the apoptotic and therapeutic activities of histone deacetylase inhibitors by using a mouse model of B cell lymphoma. Proc Natl Acad Sci U S A 2007; 104:8071-6. [PMID: 17470784 PMCID: PMC1876573 DOI: 10.1073/pnas.0702294104] [Citation(s) in RCA: 176] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Indexed: 11/18/2022] Open
Abstract
Histone deacetylase inhibitors (HDACi) can elicit a range of biological responses that affect tumor growth and survival, including inhibition of cell cycle progression, induction of tumor cell-selective apoptosis, suppression of angiogenesis, and modulation of immune responses, and show promising activity against hematological malignancies in clinical trials. Using the Emu-myc model of B cell lymphoma, we screened tumors with defined genetic alterations in apoptotic pathways for therapeutic responsiveness to the HDACi vorinostat. We demonstrated a direct correlation between induction of tumor cell apoptosis in vivo and therapeutic efficacy. Vorinostat did not require p53 activity or a functional death receptor pathway to kill Emu-myc lymphomas and mediate a therapeutic response but depended on activation of the intrinsic apoptotic pathway with the proapoptotic BH3-only proteins Bid and Bim playing an important role. Our studies provide important information regarding the mechanisms of action of HDACi that have broad implications regarding stratification of patients receiving HDACi therapy alone or in combination with other anticancer agents.
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Affiliation(s)
- R. K. Lindemann
- *Cancer Immunology Program, The Peter MacCallum Cancer Institute, Trescowthick Research Laboratories, St. Andrews Place, East Melbourne, Victoria 3002, Australia
| | - A. Newbold
- *Cancer Immunology Program, The Peter MacCallum Cancer Institute, Trescowthick Research Laboratories, St. Andrews Place, East Melbourne, Victoria 3002, Australia
| | - K. F. Whitecross
- *Cancer Immunology Program, The Peter MacCallum Cancer Institute, Trescowthick Research Laboratories, St. Andrews Place, East Melbourne, Victoria 3002, Australia
| | - L. A. Cluse
- *Cancer Immunology Program, The Peter MacCallum Cancer Institute, Trescowthick Research Laboratories, St. Andrews Place, East Melbourne, Victoria 3002, Australia
| | - A. J. Frew
- *Cancer Immunology Program, The Peter MacCallum Cancer Institute, Trescowthick Research Laboratories, St. Andrews Place, East Melbourne, Victoria 3002, Australia
| | - L. Ellis
- *Cancer Immunology Program, The Peter MacCallum Cancer Institute, Trescowthick Research Laboratories, St. Andrews Place, East Melbourne, Victoria 3002, Australia
| | - S. Williams
- *Cancer Immunology Program, The Peter MacCallum Cancer Institute, Trescowthick Research Laboratories, St. Andrews Place, East Melbourne, Victoria 3002, Australia
| | - A. P. Wiegmans
- *Cancer Immunology Program, The Peter MacCallum Cancer Institute, Trescowthick Research Laboratories, St. Andrews Place, East Melbourne, Victoria 3002, Australia
| | - A. E. Dear
- Australian Centre for Blood Diseases, Monash University, 6th Floor, Burnet Building, Prahran, Melbourne, Victoria 3181, Australia
| | - C. L. Scott
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724
- The Walter and Eliza Hall Institute, Melbourne, Victoria 3050, Australia
| | - M. Pellegrini
- The Walter and Eliza Hall Institute, Melbourne, Victoria 3050, Australia
| | - A. Wei
- The Walter and Eliza Hall Institute, Melbourne, Victoria 3050, Australia
| | - V. M. Richon
- Merck & Co., 33 Avenue Louis Pasteur, Boston, MA 02115; and
| | - Paul A. Marks
- Memorial Sloan–Kettering Cancer Center, New York, NY 10021
| | - S. W. Lowe
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724
| | - M. J. Smyth
- *Cancer Immunology Program, The Peter MacCallum Cancer Institute, Trescowthick Research Laboratories, St. Andrews Place, East Melbourne, Victoria 3002, Australia
- Department of Pathology, University of Melbourne, Parkville, Victoria 3054, Australia
| | - R. W. Johnstone
- *Cancer Immunology Program, The Peter MacCallum Cancer Institute, Trescowthick Research Laboratories, St. Andrews Place, East Melbourne, Victoria 3002, Australia
- Department of Pathology, University of Melbourne, Parkville, Victoria 3054, Australia
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Frew AJ. Mast cells in allergic diseases. Br J Clin Pharmacol 2006. [DOI: 10.1111/j.1365-2125.2006.02607.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Bonini S, Ansotegui IJ, Durham S, Frew AJ, Lötvall J, Nekam K, Popov T, Dahl R, Gayraud J, Gerth van Wijk R, Kontou-Fili K, Kowalski M, Todo-Bon A, Wahn U. Allergy and Clinical Immunology Services in Europe. Allergy 2006; 61:1191-6. [PMID: 16942567 DOI: 10.1111/j.1398-9995.2006.01081.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- S Bonini
- Second University of Naples and INMM-CNR, Rome, Italy
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Tricon S, Willers S, Smit HA, Burney PG, Devereux G, Frew AJ, Halken S, Host A, Nelson M, Shaheen S, Warner JO, Calder PC. Nutrition and allergic disease. ACTA ACUST UNITED AC 2006. [DOI: 10.1111/j.1365-2222.2006.00114.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Behndig AF, Mudway IS, Brown JL, Stenfors N, Helleday R, Duggan ST, Wilson SJ, Boman C, Cassee FR, Frew AJ, Kelly FJ, Sandström T, Blomberg A. Airway antioxidant and inflammatory responses to diesel exhaust exposure in healthy humans. Eur Respir J 2006; 27:359-65. [PMID: 16452593 DOI: 10.1183/09031936.06.00136904] [Citation(s) in RCA: 154] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pulmonary cells exposed to diesel exhaust (DE) particles in vitro respond in a hierarchical fashion with protective antioxidant responses predominating at low doses and inflammation and injury only occurring at higher concentrations. In the present study, the authors examined whether similar responses occurred in vivo, specifically whether antioxidants were upregulated following a low-dose DE challenge and investigated how these responses related to the development of airway inflammation at different levels of the respiratory tract where particle dose varies markedly. A total of 15 volunteers were exposed to DE (100 microg x m(-3) airborne particulate matter with a diameter of <10 microm for 2 h) and air in a double-blinded, randomised fashion. At 18 h post-exposure, bronchoscopy was performed with lavage and mucosal biopsies taken to assess airway redox and inflammatory status. Following DE exposure, the current authors observed an increase in bronchial mucosa neutrophil and mast cell numbers, as well as increased neutrophil numbers, interleukin-8 and myeloperoxidase concentrations in bronchial lavage. No inflammatory responses were seen in the alveolar compartment, but both reduced glutathione and urate concentrations were increased following diesel exposure. In conclusion, the lung inflammatory response to diesel exhaust is compartmentalised, related to differing antioxidant responses in the conducting airway and alveolar regions.
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Affiliation(s)
- A F Behndig
- Dept of Respiratory Medicine and Allergy, University Hospital, SE-901 85 Umeå, Sweden
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Palmer KT, McNeill Love RMC, McNeill-Love R, Poole JR, Coggon D, Frew AJ, Linaker CH, Shute JK. Inflammatory responses to the occupational inhalation of metal fume. Eur Respir J 2006; 27:366-73. [PMID: 16452594 DOI: 10.1183/09031936.06.00053205] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Occupational exposure to metal fume promotes a reversible increase in the risk of pneumonia, but by mechanisms which are unclear. To investigate, the current authors measured various markers of host defence function in welders and nonwelders. Induced sputum and venous blood samples were collected from 27 welders with regular long-term exposure to ferrous metal fume and 31 unexposed matched controls. In sputum, the present authors measured cell counts, the soluble and cellular iron concentration, and levels of interleukin-8, tumour necrosis factor-alpha, myeloperoxidase, matrix metalloproteinase-9, immunoglobulin (Ig)A, alpha(2)-macroglobulin and unsaturated iron-binding capacity. Blood samples were assayed for evidence of neutrophil activation and pneumococcal IgG antibodies. Welders had significantly higher iron levels and a substantially lower unsaturated iron-binding capacity in their sputum, but, despite a high iron challenge, there was a noteworthy absence of an inflammatory response. Only blood counts of eosinophils and basophils were significantly related to the extent of welding. Weak nonsignificant trends were observed for several other measures, consistent with low-grade priming of neutrophils. In conclusion, these data suggest that chronic exposure to metal fume blunts responsiveness to inhaled particulate matter. However, the mechanism behind the lack of detectable local inflammatory response requires further investigation.
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Affiliation(s)
- K T Palmer
- Medical Research Council (MRC) Environmental Epidemiology Unit, University of Southampton, UK.
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Heinzerling L, Frew AJ, Bindslev-Jensen C, Bonini S, Bousquet J, Bresciani M, Carlsen KH, van Cauwenberge P, Darsow U, Fokkens WJ, Haahtela T, van Hoecke H, Jessberger B, Kowalski ML, Kopp T, Lahoz CN, Lodrup Carlsen KC, Papadopoulos NG, Ring J, Schmid-Grendelmeier P, Vignola AM, Wöhrl S, Zuberbier T. Standard skin prick testing and sensitization to inhalant allergens across Europe--a survey from the GALEN network. Allergy 2005; 60:1287-300. [PMID: 16134996 DOI: 10.1111/j.1398-9995.2005.00895.x] [Citation(s) in RCA: 168] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Skin prick testing (SPT) is the standard method for diagnosing allergic sensitization but is to some extent performed differently in clinical centres across Europe. There would be advantages in harmonizing the standard panels of allergens used in different European countries, both for clinical purposes and for research, especially with increasing mobility within Europe and current trends in botany and agriculture. As well as improving diagnostic accuracy, this would allow better comparison of research findings in European allergy centres. We have compared the different SPT procedures operating in 29 allergy centres within the Global Allergy and Asthma European Network (GA(2)LEN). Standard SPT is performed similarly in all centres, e.g. using commercial extracts, evaluation after 15-20 min exposure with positive results defined as a wheal >3 mm diameter. The perennial allergens included in the standard SPT panel of inhalant allergens are largely similar (e.g. cat: pricked in all centres; dog: 26 of 29 centres and Dermatophagoides pteronyssinus: 28 of 29 centres) but the choice of pollen allergens vary considerably, reflecting different exposure and sensitization rates for regional inhalant allergens. This overview may serve as reference for the practising doctor and suggests a GA(2)LEN Pan-European core SPT panel.
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Affiliation(s)
- L Heinzerling
- Department of Dermatology and Allergy, Charité Universitätsmedizin - Berlin, Berlin, Germany
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Affiliation(s)
- A J Frew
- University of Southampton, Southampton, UK.
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Stenfors N, Nordenhäll C, Salvi SS, Mudway I, Söderberg M, Blomberg A, Helleday R, Levin JO, Holgate ST, Kelly FJ, Frew AJ, Sandström T. Different airway inflammatory responses in asthmatic and healthy humans exposed to diesel. Eur Respir J 2004; 23:82-6. [PMID: 14738236 DOI: 10.1183/09031936.03.00004603] [Citation(s) in RCA: 185] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Particulate matter (PM) pollution adversely affects the airways, with asthmatic subjects thought to be especially sensitive. The authors hypothesised that exposure to diesel exhaust (DE), a major source of PM, would induce airway neutrophilia in healthy subjects, and that either these responses would be exaggerated in subjects with mild allergic asthma, or DE would exacerbate pre-existent allergic airways. Healthy and mild asthmatic subjects were exposed for 2 h to ambient levels of DE (particles with a 50% cut-off aerodynamic diameter of 10 microm (PM10) 108 microg x m(-3)) and lung function and airway inflammation were assessed. Both groups showed an increase in airway resistance of similar magnitude after DE exposure. Healthy subjects developed airway inflammation 6 h after DE exposure, with airways neutrophilia and lymphocytosis together with an increase in interleukin-8 (IL-8) protein in lavage fluid, increased IL-8 messenger ribonucleic acid expression in the bronchial mucosa and upregulation of the endothelial adhesion molecules. In asthmatic subjects, DE exposure did not induce a neutrophilic response or exacerbate their pre-existing eosinophilic airway inflammation. Epithelial staining for the cytokine IL-10 was increased after DE in the asthmatic group. Differential effects on the airways of healthy subjects and asthmatics of particles with a 50% cut-off aerodynamic diameter of 10 microm at concentrations below current World Health Organisation air quality standards have been observed in this study. Further work is required to elucidate the significance of these differential responses.
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Affiliation(s)
- N Stenfors
- Dept of Respiratory Medicine and Allergy, University Hospital, Umeå, Sweden
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Pathmanathan S, Krishna MT, Blomberg A, Helleday R, Kelly FJ, Sandström T, Holgate ST, Wilson SJ, Frew AJ. Repeated daily exposure to 2 ppm nitrogen dioxide upregulates the expression of IL-5, IL-10, IL-13, and ICAM-1 in the bronchial epithelium of healthy human airways. Occup Environ Med 2003; 60:892-6. [PMID: 14573722 PMCID: PMC1740417 DOI: 10.1136/oem.60.11.892] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Repeated daily exposure of healthy human subjects to NO2 induces an acute airway inflammatory response characterised by neutrophil influx in the bronchial mucosa AIMS To assess the expression of NF-kappaB, cytokines, and ICAM-1 in the bronchial epithelium. METHODS Twelve healthy, young non-smoking volunteers were exposed to 2 ppm of NO2/filtered air (four hours/day) for four successive days on separate occasions. Fibreoptic bronchoscopy was performed one hour after air and final NO2 exposures. Bronchial biopsy specimens were immunostained for NF-kappaB, TNF-alpha, eotaxin, Gro-alpha, GM-CSF, IL-5, -6, -8, -10, -13, and ICAM-1 and their expression was quantified using computerised image analysis. RESULTS Expression of IL-5, IL-10, IL-13, and ICAM-1 increased following NO2 exposure. CONCLUSION Upregulation of the Th2 cytokines suggests that repeated exposure to NO2 has the potential to exert a "pro-allergic" effect on the bronchial epithelium. Upregulation of ICAM-1 highlights an underlying mechanism for leucocyte influx, and could also explain the predisposition to respiratory tract viral infections following NO2 exposure since ICAM-1 is a major receptor for rhino and respiratory syncytial viruses.
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Frew AJ. T-cell recruitment and specificity in allergic inflammation. Chem Immunol 2003; 78:135-47. [PMID: 12847725 DOI: 10.1159/000058823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- A J Frew
- University Department of Medical Specialities, University of Southampton, UK.
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Varney VA, Tabbah K, Mavroleon G, Frew AJ. Usefulness of specific immunotherapy in patients with severe perennial allergic rhinitis induced by house dust mite: a double-blind, randomized, placebo-controlled trial. Clin Exp Allergy 2003; 33:1076-82. [PMID: 12911781 DOI: 10.1046/j.1365-2222.2003.01735.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To evaluate the effectiveness of specific immunotherapy (SIT) in patients with severe house dust mite (HDM)-induced perennial allergic rhinitis using diary cards and objective endpoints. PATIENTS AND METHODS Thirty-six adult patients were selected with moderate to severe allergic rhinitis due to HDM allergy uncontrolled by regular anti-allergic drugs. Twenty-eight patients completed the study, 22 of these patients also had mild asthma. Subjects were stratified for HDM sensitivity on the basis of their 4-week diary card score and the size of their immediate and late-phase skin reaction to HDM. The groups were well matched for all relevant parameters. Patients were randomized to receive active preparation (Alutard(R)-SQ, ALK, Dermatophagoides pteronyssinus extract) or an identical placebo preparation. Increasing doses were administered until the maintenance dose was reached. This dose was then given once a month for 12 months. RESULTS Clinical efficacy was evaluated by symptom medication diary cards recorded for 4 weeks after 12 months of continuous treatment and compared with pre-treatment scores. Skin test reactivity was re-measured after 12 months of treatment to HDM, cat dander and codeine phosphate. After 1 year of treatment, the actively treated group showed a 58% reduction in diary card symptom scores (P<0.002) and a 20% reduction in the use of rescue medication. The placebo group had a 32% reduction in symptom scores (P=NS), but no reduction in rescue medication requirements. The active group showed 36% reduction in skin prick test sensitivity to D. pteronyssinus (P=0.006), while the placebo group values were unchanged. Skin reactivity to codeine was unchanged in both groups. No significant adverse reactions to SIT were encountered. CONCLUSIONS One year of SIT for D. pteronyssinus in patients with poorly controlled rhinitis (+/-mild asthma) produced clinically useful improvement as shown by symptom-medication diary cards and reductions in immediate skin reactions compared with placebo treatment.
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Affiliation(s)
- V A Varney
- RCMB Research Division, University Medicine, Southampton General Hospital, Southampton, UK.
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Bosson J, Stenfors N, Bucht A, Helleday R, Pourazar J, Holgate ST, Kelly FJ, Sandström T, Wilson S, Frew AJ, Blomberg A. Ozone-induced bronchial epithelial cytokine expression differs between healthy and asthmatic subjects. Clin Exp Allergy 2003; 33:777-82. [PMID: 12801312 DOI: 10.1046/j.1365-2222.2003.01662.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ozone (O3) is a common air pollutant associated with adverse health effects. Asthmatics have been suggested to be a particularly sensitive group. OBJECTIVE This study evaluated whether bronchial epithelial cytokine expression would differ between healthy and allergic asthmatics after ozone exposure, representing an explanatory model for differences in susceptibility. METHODS Healthy and mild allergic asthmatic subjects (using only inhaled beta2-agonists prn) were exposed for 2 h in blinded and randomized sequence to 0.2 ppm of O3 and filtered air. Bronchoscopy with bronchial mucosal biopsies was performed 6 h after exposure. Biopsies were embedded in GMA and stained with mAbs for epithelial expression of IL-4, IL-5, IL-6, IL-8, IL-10, TNF-alpha, GRO-alpha, granulocyte-macrophage colony-stimulating factor (GM-CSF), fractalkine and ENA-78. RESULTS When comparing the two groups at baseline, the asthmatic subjects showed a significantly higher expression of IL-4 and IL-5. After O3 exposure the epithelial expression of IL-5, GM-CSF, ENA-78 and IL-8 increased significantly in asthmatics, as compared to healthy subjects. CONCLUSION The present study confirms a difference in epithelial cytokine expression between mild atopic asthmatics and healthy controls, as well as a differential epithelial cytokine response to O3. This O3-induced upregulation of T helper type 2 (Th2)-related cytokines and neutrophil chemoattractants shown in the asthmatic group may contribute to a subsequent worsening of the airway inflammation, and help to explain their differential sensitivity to O3 pollution episodes.
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Affiliation(s)
- J Bosson
- Department of Respiratory Medicine and Allergy, University Hospital, Umeå, Sweden
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Abstract
During recent years an increasing focus has been directed towards the adverse health effects associated with ambient air pollution. Elderly people appear to be particularly susceptible to the adverse effects involving the respiratory and cardiovascular systems, resulting in symptoms, exacerbations of disease and even mortality. From an epidemiological point of view it is essential to obtain a more detailed description and identification of factors associated with these health effects. Novel study designs are needed with complementary exposure and biomedical characterisation. Long-term prospective studies are required. A better understanding of the pathophysiological mechanisms is considered important and requires an interaction between epidemiological and mechanistic studies in elderly individuals with or without complementary diseases that put in them especially at risk. Generally a synergy between complementary disciplines is warranted to move this important research area forward, also including in vitro models of cell responses in the elderly, animal models of diseases of the elderly, together with controlled air pollution exposure studies identifying health-related events and mechanisms. The generation of an understanding of air pollution effects in the elderly, at an elevated level, is a prerequisite to substantially reducing the adverse health effects of this population group. At local, national and European Union levels, some steps have been taken to support the research in this area. A major focus on the adverse air pollution effects in the elderly requires a long-term commitment that still remains to be established.
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Affiliation(s)
- T Sandström
- Dept of Respiratory Medicine and Allergy, University Hospital, Umea, Sweden.
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Affiliation(s)
- S Parnia
- Air Pollution Research Group, Infection Inflammation & Repair Research Division, School of Medicine, University of Southampton, UK
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Abstract
Pro-inflammatory and anti-inflammatory cytokines are important mediators in the host response to infection. In contrast to the pro-inflammatory cytokines little is known about anti-inflammatory cytokines in community-acquired pneumonia (CAP) and their relation to disease severity. Circulating levels of three pro-inflammatory cytokines (interleukin (IL)-1beta, IL-6 and tumour necrosis factor (TNF)-alpha) and two anti-inflammatory cytokines (IL-10, IL-1 receptor antagonist (IL-1ra)) were measured using an enzyme immunoassay on admission, day 3 and day 5 in 24 patients with CAP. The modified British Thoracic Society (BTS) prognostic rule and Acute Physiology and Chronic Health Evaluation (APACHE) II score were used to assess disease severity. IL-6, TNF-alpha, IL-10 and IL-1ra concentrations were detected in most patients on admission and decreased significantly on day 3 and day 5 in all survivors. A significant difference between the BTS high-risk and low-risk groups was only found for IL-6 (median (range) 477 pg x mL(-1) (7.6-1402 pg x mL(-1)) versus 81.6 pg x mL(-1) (0-943 pg x mL(-1)); p<0.05). IL-6 also correlated with the APACHE II scores on admission. Concentrations of anti-inflammatory cytokines were elevated on admission in community-acquired pneumonia but they did not correlate with disease severity scores.
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Affiliation(s)
- G Antunes
- Dept of University Medicine, Southampton General Hospital, UK
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Bakakos P, Pickard C, Wong WM, Ayre KR, Madden J, Frew AJ, Hodges E, Cawley MID, Smith JL. Simultaneous analysis of T cell clonality and cytokine production in rheumatoid arthritis using three-colour flow cytometry. Clin Exp Immunol 2002; 129:370-8. [PMID: 12165096 PMCID: PMC1906436 DOI: 10.1046/j.1365-2249.2002.01868.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
In this study we examined the cytokine production by T cells and TCRVbeta subsets in peripheral blood (PB) and synovial fluid (SF) from six RA patients and PB from 10 normal subjects, using three-colour flow cytometry. In two RA subjects we assessed T cell clonality by RT PCR using TCRBV family-specific primers and analysed the CDR3 (complementarity determining region 3) length by GeneScan analysis. A high percentage of IFN-gamma- and IL-2- producing cells was observed among the PB T cells in both the RA patients and normal controls and among the SF T cells in RA patients. In contrast, the percentage of T cells producing IL-4 and IL-5 was small among PB T cells in both RA patients and normal controls and among SF T cells in RA patients. There was no significant difference in the production of IFN-gamma, IL-2 and IL-5 between the two compartments (PB and SF); however, there were significantly more IL-4-producing cells in SF. Molecular analysis revealed clonal expansions of four TCRBV families in SF of two of the RA patients studied: TCRBV6.7, TCRBV13.1 and TCRBV22 in one and TCRBV6.7, TCRBV21.3 and TCRBV22 in the second. These expansions demonstrated cytokine expression profiles that differed from total CD3+ cells, implying that T cell subsets bearing various TCR-Vbeta families may have the potential to modulate the immune response in RA patients.
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Affiliation(s)
- P Bakakos
- Department of University of Medicine, Southampton General Hospital, Southampton, UK
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Frew AJ, Langley SJ, Perrin V, Hertog MGL. Effects of 4-week treatment with low-dose budesonide (100 micrograms BID) from a novel inhaler Airmax and from a conventional inhaler on bronchial hyper-responsiveness, lung function and symptoms in patients with mild asthma. Respir Med 2002; 96:542-7. [PMID: 12194641 DOI: 10.1053/rmed.2002.1290] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This study investigated the effect of low dose of budesonide 100 micrograms b.d from a new multi-dose dry powder inhaler (Airmax) and from a conventional inhaler (Turbuhaler) on bronchial hyper-responsiveness, lung function and asthma symptoms in mild stable asthmatics. Twenty-five patients were enrolled into a double-blind double-dummy crossover study with two 4-week treatment periods separated by a 4-week washout. Patients had a mean forced expiratory volume in 1 s (FEV1) of 91 +/- 13% predicted, had previously received inhaled short-acting beta 2-agonists only and had a PC20 to adenosine 5' monophosphate (AMP) < 40 mg/ml. PC20 AMP was assessed at baseline, and at the start and end of each treatment period. Patients recorded peak expiratory flow and symptoms throughout the study. There was a mean increase in PC20AMP from start to end of 3.49 doubling dilutions (DD) in the Airmax group and 2.90 DD in the Turbuhaler group. The difference was 0.60 DD (95% CI--0.47, 1.69) favouring Airmax and the upper limit exceeded the equivalence limit of +/- 1 DD. There were similar improvements in FEV1, daily PEF and symptoms in both groups. The majority of patients preferred treatment with Airmax to Turbuhaler (64 vs. 23%). Both treatments were equally well tolerated. In conclusion, 100 micrograms budesonide bid during 4 weeks from Airmax effectively attenuates the response to AMP in mild asthmatics. Overall Airmax offers equal clinical benefit to Turbuhaler.
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Affiliation(s)
- A J Frew
- Department of Respiratory Medicine, Southampton General Hospital, Southampton, U.K
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Stenfors N, Pourazar J, Blomberg A, Krishna MT, Mudway I, Helleday R, Kelly FJ, Frew AJ, Sandström T. Effect of ozone on bronchial mucosal inflammation in asthmatic and healthy subjects. Respir Med 2002; 96:352-8. [PMID: 12113386 DOI: 10.1053/rmed.2001.1265] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Epidemiological studies suggestthat asthmatics are more affected by ozone than healthy people. This study tested three hypotheses (1) that short-term exposure to ozone induces inflammatory cell increases and up-regulation of vascular adhesion molecules in airway lavages and bronchial tissue 6 h after ozone exposure in healthy subjects; (2) these responses are exaggerated in subjects with mild allergic asthma; (3) ozone exacerbates pre-existent allergic airways inflammation. We exposed 15 mild asthmatic and 15 healthy subjects to 0.2 ppm of ozone or filtered air for 2 h on two separate occasions. Airway lavages and bronchial biopsies were obtained 6 h post-challenge. We found that ozone induced similar increases in bronchial wash neutrophils in both groups, although the neutrophil increase in the asthmatic group was on top of an elevated baseline. In healthy subjects, ozone exposure increased the expression of the vascular endothelial adhesion molecules P-selectin and ICAM- 1, as well as increasing tissue neutrophil and mast cell numbers. The asthmatics showed allergic airways inflammation at baseline but ozone did not aggravate this at the investigated time point. At 6 h post-ozone-exposure, we found no evidence that mild asthmatics were more responsive than healthy to ozone in terms of exaggerated neutrophil recruitment or exacerbation of pre-existing allergic inflammation. Further work is needed to assess the possibility of a difference in time kinetics between healthy and asthmatic subjects in their response to ozone.
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Affiliation(s)
- N Stenfors
- Department of Respiratory Medicine and Allergy, University Hospital, Umeå, Sweden
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Abstract
T cells are thought to play an important regulatory role in atopic asthma. We hypothesized that human blood and BAL T cell subsets bearing various TCR-Vbeta genes might show selective differences in their cytokine profile. Peripheral blood (PB) and bronchoalveolar lavage (BAL) T cells from seven atopic asthmatic and six non-atopic non-asthmatic subjects were stimulated with PMA and ionomycin in the presence of monensin and analysed for TCR-Vbeta expression and production of cytokines at the single cell level. The percentage of IFN-gamma- and IL-2-producing BAL T cells was elevated compared with PB T cells from both the asthmatic subjects and the non-atopic, non-asthmatic controls. A small percentage of PB and BAL T cells produced IL-4 and IL-5, in asthmatic and normal subjects. In peripheral blood, the percentage of T cells expressing each cytokine was similar in the various TCR-Vbeta subsets and in total CD3+ T cells in all normal and six of seven asthmatic subjects. However, there was a substantial degree of heterogeneity in the cytokine profile of BAL TCR-Vbeta subsets compared with the total CD3+ T cells. This was more obvious in the asthmatic subjects with a reduction in the percentage of IFN-gamma- and IL-2-expressing T cells (five of seven asthmatic subjects) and an increase in the percentage of IL-4- and IL-5-expressing T cells (two of seven asthmatic subjects). These data confirm previous findings of an elevated proportion of IFN-gamma- and IL-2-producing BAL T cells while only a small proportion of PB and BAL T cells produce IL-4 and IL-5. Moreover, subsets of BAL T cells, defined by their TCR-Vbeta usage, may differ in their cytokine profile compared with the total CD3+ T cells, implying that T cells expressing different Vbeta elements may play different roles in regulating the airway inflammation in asthma.
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Affiliation(s)
- P Bakakos
- Infection, Inflammation and Repair Research Division, School of Medicine, University of Southampton, UK
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Abstract
LEARNING OBJECTIVES The purpose of this review is to objectively critique available data regarding the role of diesel exhaust particles (DEPs) in allergic disease. Readers of this review should understand the ways in which diesel particulates can affect human airways and the extent of the scientific data which are currently available. DATA SOURCES Data were obtained from published studies and reviews. STUDY SELECTION The specific reviewed studies selected for this review met the following criteria: human and animal in vivo, in vitro, and pulmonary dosimetry studies, as well as epidemiologic studies to examine the role of DEPs and particulates on the airways. RESULTS The results of the published studies show that although DEPs may play a role in the increased levels of allergic disorders through a number of immunologic mechanisms, it remains to be proven whether it is responsible for the recent rise in the prevalence of asthma and other allergic disorders. CONCLUSIONS Further studies in humans are needed to elucidate the mechanisms by which DEPs may be responsible for the increased prevalence of allergic disorders.
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Affiliation(s)
- S Parnia
- Respiratory Cell & Molecular Biology Research Division, School of Medicine, Southampton General Hospital, United Kingdom.
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Mudway IS, Stenfors N, Blomberg A, Helleday R, Dunster C, Marklund SL, Frew AJ, Sandström T, Kelly FJ. Differences in basal airway antioxidant concentrations are not predictive of individual responsiveness to ozone: a comparison of healthy and mild asthmatic subjects. Free Radic Biol Med 2001; 31:962-74. [PMID: 11595381 DOI: 10.1016/s0891-5849(01)00671-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The air pollutant ozone induces both airway inflammation and restrictions in lung function. These responses have been proposed to arise as a consequence of the oxidizing nature of ozone, depleting endogenous antioxidant defenses with ensuing tissue injury. In this study we examined the impact of an environmentally relevant ozone challenge on the antioxidant defenses present at the surface of the lung in two groups known to have profound differences in their antioxidant defense network: healthy control (HC) and mild asthmatic (MA) subjects. We hypothesized that baseline differences in antioxidant concentrations within the respiratory tract lining fluid (RTLF), as well as induced responses, would predict the magnitude of individual responsiveness. We observed a significant loss of ascorbate (ASC) from proximal (-45.1%, p <.01) and distal RTLFs (-11.7%, p <.05) in healthy subjects 6 h after the end of the ozone challenge. This was associated (Rs, -0.71, p <.01) with increased glutathione disulphide (GSSG) in these compartments (p =.01 and p <.05). Corresponding responses were not seen in asthmatics, where basal ASC concentrations were significantly lower (p <.01) and associated with elevated concentrations of GSSG (p <.05). In neither group was any evidence of lipid oxidation seen following ozone. Despite differences in antioxidant levels and response, the magnitude of ozone-induced neutrophilia (+20.6%, p <.01 [HC] vs. +15.2%, p =.01 [MA]) and decrements in FEV(1) (-8.0%, p <.01 [HC] vs. -3.2%, p <.05 [MA]) did not differ between the two groups. These data demonstrate significant differences between the interaction of ozone with RTLF antioxidants in MA and HC subjects. These responses and variations in basal antioxidant defense were not, however, useful predictive markers of group or individual responsiveness to ozone.
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Affiliation(s)
- I S Mudway
- School of Health and Life Sciences, Kings' College London, London, UK
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Abstract
Glucocorticosteroids are the backbone of asthma therapy and are administered mainly by the inhaled route. Patients with "difficult" asthma are not a single homogeneous group. Some are stable on high-dose steroid therapy but experience unacceptable side effects; others remain unstable despite receiving high doses of inhaled or oral steroids. Several different steroid-sparing and alternative agents have been tried, with varying degrees of success. Some success has been achieved with conventional immunosuppressants such as methotrexate, gold, and cyclosporin A, but these agents can be justified only in a limited range of cases. Leukotriene receptor antagonists have proved a useful addition to asthma therapy and have been shown to have a modest steroid-sparing effect. Although the existing range of alternative agents has not proved to be particularly effective, several new therapeutic agents have been developed to target specific components of the inflammatory process in asthma. These include IgE antibodies, cytokines, chemokines, and vascular adhesion molecules. Future developments might include better forms of immunotherapy and strategies targeting the remodeling of structural elements of the airways.
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Affiliation(s)
- A J Frew
- Department of Medical Specialties, School of Medicine, University of Southampton, United Kingdom
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Haney SM, Thompson PM, Cloughesy TF, Alger JR, Frew AJ, Torres-Trejo A, Mazziotta JC, Toga AW. Mapping therapeutic response in a patient with malignant glioma. J Comput Assist Tomogr 2001; 25:529-36. [PMID: 11473181 DOI: 10.1097/00004728-200107000-00004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Short-interval scanning of patients offers a detailed understanding of the natural progression of tumor tissue, as revealed through imaging markers such as contrast enhancement and edema, prior to therapy. Following treatment, short-interval scanning can also provide evidence of attenuation of growth rates. We present a longitudinal imaging study of a patient with glioblastoma multiforme (GBM) scanned 15 times in 104 days on a 3 T MR scanner. Images were analyzed independently by two automated algorithms capable of creating detailed maps of tumor changes as well as volumetric analysis. The algorithms, a nearest-neighbor-based tissue segmentation and a surface-modeling algorithm, tracked the patient's response to temozolomide, showing an attenuation of growth. The need for surrogate imaging end-points, of which growth rates are an example, is discussed. Further, the strengths of these algorithms, the insight gained by short-interval scanning, and the need for a better understanding of imaging markers are also described.
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Affiliation(s)
- S M Haney
- Laboratory of Neuro Imaging, Division of Brain Mapping, Department of Neurology, UCLA School of Medicine, Los Angeles, CA 90095-1769, USA
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Abstract
Recent claims have been made that sublingual immunotherapy (SLIT) may be a viable alternative to injection immunotherapy (SIT). Animal studies show that when allergens are administered topically, they are handled differently, and IgE responses can be reduced. Most published studies of human SLIT have been small but show fairly consistent benefits on symptom scores, with few systemic side effects. Objective measures of allergen reactivity usually do not change. Relatively few subjects have been treated in SLIT trials compared with the numbers that would be required to validate new drug therapies. On the plus side, SLIT appears to work in adults and in children; it offers some logistic advantages and seems to be safe. Giving allergen by mouth rather than by injection should decrease the costs of immunotherapy, but the cumulative dose of allergen used in SLIT has been between 20 to 375 times the dose given in conventional SIT. Further cost-benefit analysis is needed. On the other hand, standard SIT is effective and is supported by better clinical and experimental evidence. The balance sheet for SLIT is improving, but on the current evidence, SLIT requires further evaluation before it could be recommended for use in routine clinical practice.
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Affiliation(s)
- A J Frew
- Department of Medical Specialties, School of Medicine, University of Southampton, UK
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Redington AE, Roche WR, Madden J, Frew AJ, Djukanovic R, Holgate ST, Howarth PH. Basic fibroblast growth factor in asthma: measurement in bronchoalveolar lavage fluid basally and following allergen challenge. J Allergy Clin Immunol 2001; 107:384-7. [PMID: 11174209 DOI: 10.1067/mai.2001.112268] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Airway remodeling in asthma refers to a collection of chronic structural changes including subepithelial fibrosis, airway smooth muscle hypertrophy/hyperplasia, and possibly angiogenesis. The mechanisms leading to remodeling are not well defined. One molecule of possible relevance is basic fibroblast growth factor (bFGF), which is a potent mitogen for fibro-blasts, airway smooth muscle cells, and endothelial cells. To test the hypothesis that bFGF expression is increased in asthma, we measured levels of the growth factor in bronchoalveolar lavage (BAL) fluid. Basally, BAL fluid bFGF concentrations were significantly higher in subjects with atopic asthma than in control subjects without asthma (median 0.22 vs 0.06 pg/mL, P = .003). The effect of acute allergen exposure was examined with a segmental bronchoprovocation model in a separate group of subjects with atopic asthma. Ten minutes after segmental bronchoprovocation there was a 5-fold increase in bFGF levels in BAL fluid recovered from allergen-challenged sites compared with control saline-challenged sites (1.52 vs 0.30 pg/mL, P < .002). We conclude that basal levels of BAL fluid bFGF are increased in atopic asthma and that a further increase occurs in response to acute allergen exposure. These findings lend support to the hypothesis that bFGF is implicated in airway remodeling in asthma.
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Affiliation(s)
- A E Redington
- University Medicine and University Pathology, Southampton General Hospital, United Kingdom
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