Adverse events in children and adolescents undergoing allergen immunotherapy for respiratory allergies-Report from the Allergen Immunotherapy Adverse Events Registry (ADER), a European Academy of Allergy and Clinical Immunology taskforce

BACKGROUND

Although it has been shown that allergen immunotherapy (AIT) is well-tolerated in children, systematic and prospective surveillance of AIT safety in real life settings is needed.

METHODS

The multinational Allergen Immunotherapy Adverse Events Registry (ADER) was designed to address AIT safety in real life clinical practice. Data on children ≤18 years old with respiratory allergies undergoing AIT were retrieved. Patient- and AIT-related features were collected and analyzed. The characteristics of adverse events (AE) and risk factors were evaluated.

RESULTS

A total of 851 patients, 11.3 ± 3.4 years old, with rhinitis only (47.6%); asthma and rhinitis (44.5%); asthma (7.9%), receiving 998 AIT courses were analyzed. Sublingual immunotherapy (SLIT) accounted for 51% of the courses. In 84.5% of patients only one AIT treatment was prescribed. Pollen was the most frequent sensitizer (57.1%), followed by mites (53.4%), molds (18.2%) and epithelia (16.7%). Local and systemic AEs were reported in 85 patients (9.9%). Most AEs (83.1%) were mild and occurred in <30 min (87%). Respiratory and cutaneous symptoms were more frequent. Only 4 patients (0.47%) had severe AE (none after 6 weeks of maintenance). The risk of AE was higher in patients undergoing SCIT.

CONCLUSIONS

AIT is safe and well tolerated in children and adolescents with respiratory allergies in real-life clinical practice. Though SCIT is more prone to AE compared to SLIT, overall severe reactions are rare and occur during build-up and early maintenance.

What happens to basophils and tryptase, LXA4 and CysLTs during aspirin desensitization?

INTRODUCTION

Aspirin desensitization (AD) is an effective treatment in patients with non-steroidal anti-inflammatory drugs (NSAID)-exacerbated respiratory disease (NERD) by providing inhibitory effect on symptoms and polyp recurrence. However, limited data is available on how AD works. We aimed to study comprehensively the mechanisms underlying AD by examining basophil activation (CD203c upregulation), mediator-releases of tryptase, CysLT, and LXA₄, and LTB₄ receptor expression for the first 3 months of AD.

METHODS

The study was conducted in patients with NERD who underwent AD (group 1: n = 23), patients with NERD who received no desensitization (group 2: n = 22), and healthy volunteers (group 3, n = 13). All participants provided blood samples for flow cytometry studies (CD203c and LTB₄ receptor), and mediator releases (CysLT, LXA_4, and tryptase) for the relevant time points determined.

RESULTS

All baseline parameters of CD203c and LTB₄ receptor expressions, tryptase, CysLT, and LXA₄ releases were similar in each group (p > 0.05). In group 1, CD203c started to be upregulated at the time of reactions during AD, and continued to be high for 3 months when compared to controls. All other study parameters were comparable with baseline and at the other time points in each group (p > 0.05).

CONCLUSION

Although basophils are active during the first 3 months of AD, no releases of CysLT, tryptase or LXA₄ exist. Therefore, our results suggest that despite active basophils, inhibition of mediators can at least partly explain underlying the mechanism in the first three months of AD.

Economic burden of severe asthma in Turkey: a cost of illness study from payer perspective

Summary

Objective. To estimate economic burden of severe asthma in Turkey from payer perspective based on expert panel opinion on practice patterns in clinical practice. Methods. This cost of illness study was based on identification of per patient annual direct medical costs for the management of sever easthma in Turkey from payer perspective. Average per patient direct medical cost was calculated based on cost items related to outpatient visits, laboratory and radiological tests, hospitalizations and interventions, drug treatment and equipment, and co-morbidities/complications. Results. Based on total annual per patient costs calculated for outpatient admission ($ 177.91), laboratory and radiological tests ($ 82.32), hospitalizations/interventions ($ 1,154.55), drug treatment/equipment ($ 2,289.63) and co-morbidities ($ 665.39) cost items, total per patient annual direct medical costrelated to management of severe asthma was calculated to be $ 4,369.76 from payer perspective. Drug treatment/equipment (52.4%) was the main cost driver in the management of severe asthma in Turkey, as followed by hospitalizations/interventions (26.4%) and co-morbidities (15.2%). Conclusions. In conclusion, our findings indicate that managing patients with severe asthma pose a considerable burden to health economics in Turkey, with medications as the main cost driver.

Demographic, Clinical and Management Characteristics of Newly Diagnosed COPD Patients in Turkey: A Real-Life Study

Purpose

In order to determine the clinical and sociodemographic characteristics of newly diagnosed treatment-naïve asthma and COPD patients in Turkey, a multicenter study in 2012 was initiated . We aimed to investigate the characteristics and therapies of COPD patients in the original study in more detail.

Patients and Methods

This nation-wide, multicentric, non-interventional, prospective, real-life observational cohort study was conducted in 122 centers. The newly diagnosed patients were not receiving any treatment before the recruitment. Their general characteristics, the combined GOLD 2011 COPD categories and exacerbation histories were noted. The patients were followed up with 3 voluntary visits for 1 year. Their adherence to the inhaled treatment according to GOLD 2011 was evaluated during follow-up visits.

Results

The study included 776 COPD patients. Their mean age was 59.4±9.1 years, and 11.9% of the patients were female. 35.1% of the patients were in the GOLD 2011 C and D category. 12.6% are frequent exacerbators, and 52.8% had at least one comorbid condition. 71.8% overtreatment rate was detected. Their attendance rates for three follow-up visits became 55.9%, 32.9% and 18.7%, respectively. The adherence rate to the treatment was measured as 81.9%.

Conclusion

Although these patients were diagnosed for the first time, the GOLD C and D categories and frequent exacerbator phenotype were found at a high rate. They were usually prescribed an overtreatment regimen. We think that newly diagnosed COPD patients should be evaluated carefully, and best effort should be made to treat these patients in accordance with the recommendations of the major COPD guidelines.

Omalizumab in the treatment of eosinophilic granulomatosis with polyangiitis (EGPA): single-center experience in 18 cases

BACKGROUND

Data are limited regarding the effectiveness of omalizumab in patients with eosinophilic granulomatosis with polyangiitis (EGPA). Our aim was to evaluate the clinical and functional effectiveness of omalizumab in patients with EGPA in long-term follow-up.

METHODS

This study was a retrospective chart review of patients with EGPA who were treated with omalizumab injections between May 2012 and April 2018. Once treatment with omalizumab was started, data were collected at various time points: baseline, the 16th week, 1st year, and annually until the last evaluation.

RESULTS

Eighteen patients (16F/2M) with a mean age of 48.61 ± 11.94 years were included. Data were available for all patients for the first year, 12 patients for the second year, 10 patients for the third  year, 8 patients for the fourth  year and 5 patients for the fifth year. All patients were on mean dosage of 15.77 ± 7.6 mg/day oral corticosteroid (OCS) as daily bases for mean 8.61 ± 4 years besides high-dose inhaler corticosteroid/long-acting beta agonist. Antineutrophil cytoplasmic antibodies (ANCA) were positive in 2  patients, and 8 patients were diagnosed as having vasculitis by skin biopsy, one patient had polyneuropathy, and one patient had cardiac involvement.By considering the individual responses of patients and the level of improvement at the last evalulation, 10 (55.6%) patients responded completely, 1 responded partially, and 7 (38.9%) had no improvement. Omalizumab worked as a steroid-sparing agent in all patients and the daily OCS dose was reduced with a mean dosage of 6.28 mg/day at the end of the first year. The mean OCS reduction time for the whole group was 4 months. A reduction in asthma exacerbations/hospitalizations, improvement in forced expiratory volume in 1 second, and no decrease in the eosinophil count during treatment with omalizumab were also observed.

CONCLUSIONS

Omalizumab improved asthma control in some patients with EGPA with uncontrolled asthma by reducing asthma exacerbations and oral steroid requirement. However, more data are needed before recommending widespread use of omalizumab in patients with EGPA.

Is Adenoidectomy and/or Tonsillectomy a Risk Factor for Allergic Diseases and Asthma in Adulthood?

Objective

To determine the relationship between adenoidectomy and/or tonsillectomy in childhood and allergic diseases in adulthood.

Materials and Methods

A survey investigating the history of adenoidectomy and/or tonsillectomy was administered to patients that were followed-up by our department between January and June 2014 with the diagnosis of asthma, allergic rhinitis, urticaria-angioedema, drug allergy, food allergy, and venom allergy; patients willing to participate were included in the study. The relationship and risk ratios were analyzed.

Results

Totally, 510 (female/male: 379/131) patients were included in the study: 248 with asthma, 205 with rhinitis, 82 with drug allergy, 73 with urticaria, 24 with food allergy, and 14 with venom allergy. Of these, 65 (12.7%) had undergone adenoidectomy and/or tonsillectomy. Of these 65 patients, 41 had asthma, 33 had allergic rhinitis, and 28 had other allergic diseases. No relation between the history of atopy and adenoidectomy and/or tonsillectomy (p=0.129) was detected; however, there was a positive correlation between asthma and patients aged <15 years having a history of tonsillectomy and/or adenoidectomy (p=0.020). The risk of asthma was determined to be increased by 1.96 fold among the patients, provided the patient had undergone adenoidectomy and/or tonsillectomy (confidence interval [CI]:1.14-3.36). No connection was observed between atopic and non-atopic asthmatic patients in relation to adenoidectomy and/or tonsillectomy (p=0.46). No relationship was observed between allergic rhinitis and adenoidectomy and/or tonsillectomy.

Conclusion

Adenoidectomy and/or tonsillectomy in childhood increase the risk of asthma in adulthood, whereas it does not increase the risk of atopy. This result signifies the criticality of adenoidectomy or tonsillectomy in the pathogenesis of asthma.

Asthma control and adherence in newly diagnosed young and elderly adult patients with asthma in Turkey

OBJECTIVE

This study aimed to evaluate the factors that affect asthma control and adherence to treatment in newly diagnosed elderly asthmatics in Turkey compared with younger patients.

METHODS

This real-life prospective observational cohort study was conducted at 136 centers. A web-based questionnaire was administered to the patients who were followed up for 12 months.

RESULTS

Analysis included 1037 young adult asthma patients (age <65 years) and 79 elderly asthma patients (age ≥65 years). The percentage of patients with total control in the elderly and young groups were 33.9% and 37.1% at visit 1, 20.0% and 42.1% (p = 0.012) at visit 2, and 50.0% and 49.8% at visit 3, respectively. Adherence to treatment was similar for both groups. Visit compliance was better in the elderly group than in the young group at visit 1 (72.2% vs. 60.8%, p = 0.045), visit 2 (51.9% vs. 34.9%, p = 0.002), and visit 3 (32.9% vs. 19.4%, p = 0.004). Adherence to treatment increased with asthma control in both groups (both p < 0.001) but decreased with the presence of gastritis/ulcer, gastroesophageal reflux, and coronary artery disease in the elderly.

CONCLUSIONS

Asthma control and adherence to treatment were similar for the elderly and young asthma patients, though the follow-up rate was lower in young patients. The presence of gastritis/ulcer, gastroesophageal reflux and coronary artery disease had negative impacts on the adherence to treatment in elderly adult patients.

Does the medical diagnosis of occupational asthma coincide with the legal diagnosis?

OBJECTIVE

The incidence of occupational asthma (OA) is increasing worldwide. In this study, we first aimed to document the rate of diagnosis of OA among patients who were referred to our clinic from the Social Security Institution and the factors that affected diagnosis; secondly, we aimed to assess the consistency of the medical and legal diagnoses.

METHODS

The study involved 132 consecutive patients who were referred to our clinic for the evaluation of OA between 2010 and 2015. Detailed workplace history, the tools used in the diagnosis such as peak expiratory flow (PEF) monitoring and bronchial provocation tests, and the final medical diagnosis were recorded from case files.

RESULTS

Asthma was diagnosed in 75% (n = 99) of the patients. Among them, 22.2% were diagnosed as having OA. The diagnosis was confirmed by serial PEF measurements, non-specific bronchial hyperreactivity assessment or both of the tests both at work and off-work periods. OA diagnosis was mostly established in active workers (72.7%). The legal diagnosis period was completed in 54.5% of these 22 patients, and 50% (n = 11) were officially diagnosed as having OA with a 91.6% concordance with medical diagnosis.

CONCLUSION

This study verifies the importance of diagnosing asthma correctly as a first step in the evaluation of OA. Diagnostic tests other than specific provocation tests could be preferential in patients who still work in the same field. We believe that cooperation with the patient's occupational physician and adequate recognition of the work environment will improve the consistency of legal and medical diagnoses.

Immunologic alterations and efficacy of subcutaneous immunotherapy with Dermatophagoides pteronyssinus in monosensitized and polysensitized patients

BACKGROUND

There is a continuing debate about whether monoallergen subcutaneous immunotherapy (SCIT) is able to modulate immune and clinical responses toward main causal allergen in polysensitized patients.

OBJECTIVE

To investigate short-term immunologic changes and clinical effectiveness of SCIT with Dermatophagoides pteronyssinus in monosensitized and polysensitized patients who have rhinitis with or without asthma.

METHODS

Nineteen monosensitized and 24 polysensitized patients participated in this prospective, self-placebo-controlled, interventional study. Cluster immunotherapy with D pteronyssinus was administered after 2 months of placebo in both groups. Immunologic parameters, including CD203c expression on basophils after allergen stimulation, total IgE, specific IgE, and specific IgG4, were evaluated at baseline, after placebo, and after immunotherapy. Clinical effectiveness was assessed using monthly symptom-medication scores, visual analog scale, quality-of-life questionnaire, and nasal allergen provocation test.

RESULTS

At baseline, polysensitized patients had higher CD203c expression on basophils than monosensitized patients (P = .007). Activated basophils expressing CD203c, total IgE, and specific IgG4 were significantly increased after immunotherapy compared with baseline and placebo in the polysensitized group (P < .025). After immunotherapy, specific IgE and D pteronyssinus-induced CD203c expression were significantly higher in polysensitized than monosensitized patients (P < .05). The total symptom scores and the Mini Rhinoconjunctivitis Quality of Life Questionnaire scores in polysensitized patients and the visual analog scale scores in both groups were lower after immunotherapy compared with baseline and placebo (P < .025). Titrated nasal allergen provocation test with D pteronyssinus increased after immunotherapy in the monosensitized group (P < .05).

CONCLUSION

This study indicates that monosensitized and polysensitized patients have distinct humoral response and basophil behavior to SCIT. However, a single-allergen immunotherapy corresponding to the most clinically troublesome allergy in polysensitized patients can lead to early clinical efficacy comparable to that seen in monosensitized patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01795846.

Cat and dog sensitization in pet shop workers

BACKGROUND

Sensitivity and symptoms related to animal proteins have been investigated in various occupational groups. However, data from pet shops are limited.

AIMS

To investigate rates of sensitivity to cats and dogs among pet shop workers, to assess the relationship between sensitivity, allergen levels and symptoms and to investigate whether passive transport from pet shops to homes is possible.

METHODS

Pet shop workers underwent interviews with a questionnaire adapted from the European Community Respiratory Health Survey. Dust samples for allergen detection were collected from pet shops using a vacuum cleaner. Skin tests were performed with common allergens. Dust samples were also obtained from the houses of 7 workers and 12 control subjects.

RESULTS

Fifty-one workers from 20 pet shops were included in the study. Thirteen (25%) workers reported work-related symptoms. Four workers had sensitivity to animal allergens. The mean cat/dog allergen levels from pet shops were 15.7 and 3.2 µg/g, respectively. There was no significant relationship between cat/dog allergen levels and work-related symptoms and sensitivity to pets. None of the dust samples collected from the homes of pet shop workers contained cat allergens. Dog allergen was detected in only one house (0.58 µg/g). Neither cat nor dog allergens were found in the homes of the 12 control subjects.

CONCLUSIONS

Although a quarter of pet shop workers reported work-related symptoms, sensitivity to cat and dog was low. These findings suggest that work-related symptoms may be due to other factors than cat and dog sensitivity.

Hypersensitivity pneumonitis in children: pigeon breeders disease

Hypersensitivity pneumonitis (HP), an extrinsic allergic alveolitis, is a group of immunologically mediated, diffuse inflammatory lung parenchymal diseases. Pigeon breeder's disease (PBD) is one of the most common clinical forms of HP. It is caused by inhalation of various pigeon-derived materials and can present in different clinical forms. The diagnosis is difficult and the best diagnostic tool is correlation of onset of symptoms with time of exposure. Precipitating antibodies against the avian proteins form the characteristic precipitin reactions. The most effective treatment is avoidance of the antigens. Steroids, either systemic or topical (inhalational), can be used to treat HP. We report five children with different clinical forms of PBD in whom the diagnosis was confirmed by positive serum precipitating antibodies to avian proteins. Although the disease is rarely seen in children, it should be considered in any child with recurrent or unexplained respiratory symptoms. Nebulising steroids might be a useful alternative treatment for allergic alveolitis.

Does drug compliance change in asthmatic patients during pregnancy?

Background: Pregnant women with asthma are recommended to maintain optimal therapeutic management during pregnancy. Uncontrolled, symptomatic asthma may increase the risk of adverse peri-natal outcomes; thus adequate regular anti-asthmatic treatment must be given to provide optimal asthma control during pregnancy. However, doubts about the safety of asthmatic drugs can affect pregnant asthmatic patients’ drug compliance. The aim of this study was to assess behavioral differences in drug compliance among pregnant asthmatic patients. Methods: Thirty two asthmatic and 121 healthy pregnant women were enrolled in the study. Structured face-to-face interviews were conducted after delivery. The interviews included disease characteristics, drug compliance and patients’ own perspective for asthma status prior to and during pregnancy. In addition, medical and pregnancy history, pregnancy complications and outcomes, and newborn characteristics were recorded. Results: In our study group the rates of hospitalization, emergency room visits and systemic steroid use in the year before pregnancy were 13%, 46.9% and 18.8%, respectively. The rate of regular asthma medication use was only 32% at that period and increased to 44% during pregnancy. However, hospitalization, emergency room visits, systemic steroid usage rates remained unchanged and according to patients’ own evaluations, 44% of asthmatics pointed out that their asthma had worsened during pregnancy. No statistically significant difference was detected in terms of pregnancy/labour complication between asthmatic and non-asthmatics. Conclusions: Contrary to some previous studies, in our study regular use of asthma drugs increased during pregnancy. The uncontrolled condition of their asthma before and during pregnancy and the idea that their asthma worsened during pregnancy might force the patients to use medication more regularly.

Self-reported knowledge and approaches toward complementary and alternative medicine among physicians dealing with allergic diseases

Considering the popularity of Complementary and Alternative Medicine (CAM) in allergic patients, physicians involved in allergic patients' care need to be aware of CAM. To assess self-reported knowledge, attitude and approach to CAM of physicians who deal with allergic patients, a total of 500 structured questionnaires were distributed to physicians who participated in "Turkish National Society of Allergy and Clinical Immunology Congress-2009". For the questionnaires handed out, 242 (48.4%) physicians (median age 36.0 years, range 25-64 years) responded; 22.4% were fellows in training and 48.5% were residents. The main specialties were pediatrics (49.3%), and pulmonology (36.8%); half were either specialists or training in allergy and one-quarter (25.6%) referred patients to CAM. Asthma (42.1%) and chronic urticaria (28.9%) were the most common CAM referral diseases. Referred therapies were herbal (10.3%) and diet-based medicine (7.4%). The differences between physicians in terms of age, gender, experience in medicine, and specialty/allergy subspecialty were not statistically significant (p = 0.01). Affiliation to a university hospital was significantly associated with no CAM referral vs. affiliation in a state/private hospital or private practice. Academic degree and reported level of knowledge negatively/positively affected attitudes toward CAM, respectively. More than half of the respondents (68.8%) reported lack of or insufficient information about CAM, while 58.7% of physicians desired CAM education. This first report on physicians involved in allergic patients' care shows that they are reluctant to refer for CAM therapies. A minority believes that they have enough knowledge, and most are interested in continuing medical education on CAM. Considering physicians' interest and tendency to communicate significantly with their patients about CAM when they feel that they have sufficient knowledge and popularity of CAM among patients, training possibilities should be created to improve physicians' education in this field.

A case of uncontrolled asthma

A 48-year-old female patient with uncontrolled severe asthma was referred to our hospital for anti-IgE therapy. She was suffering with persistent wheezing and dyspnea after a severe asthma attack that had taken place 5 months previously. Her asthma had not been controlled with adequate asthma treatment, including budesonide at 320 μg + formoterol at 9 μg b.i.d. combination, montelukast at 10 mg/day, and oral steroids (30-40 mg/day of prednisolone), during this period. She was hospitalized for evaluation for anti-IgE therapy. Chest radiography revealed a left-sided hilar opacity. Fiberoptic bronchoscopy was performed and showed an endobronchial lesion obstructing the left lower bronchus lumen. Computed tomography also revealed a nodular lesion at the same location. The patient underwent left lower lobectomy and mediastinal lymph node dissection. Pathological examination concluded the diagnosis of typical carcinoid tumor. After surgery, her symptoms disappeared and she has had no recurrence. In conclusion, a diagnosis of severe asthma requires confirmation of asthma. Uncontrolled symptoms that linger despite aggressive therapy warrant evaluation to rule out other etiologies, such as a carcinoid tumor, before selecting new treatment options.

Allergy to hazelnut in adults: a two-step study

BACKGROUND

Although hazelnut consumption is very high in Turkey, the prevalence of hazelnut allergy is still unknown. This study's objective was to investigate the prevalence of hazelnut sensitisation and to verify its clinical importance using double-blind, placebo-controlled challenge (DBPCFC) in an adult population.

METHODS

Prick-to-prick skin tests were performed with fresh hazelnut in 904 patients admitted to the allergy department. Among the 904 subjects, 20 patients with a history of allergic reactions to hazelnut and/or positive skin tests were recalled for further evaluation. Specific IgE was measured in these subjects. Eleven (11/20) patients accepted to undergo DBPCFC with hazelnut.

RESULTS

Among the 904 individuals, the history of reactions to hazelnut was positive in 16 subjects (1.8%); prick-to-prick skin tests were positive in 13 (1.4%); prick tests with the commercial product were positive in nine (0.9%); and history plus skin tests were positive in 16 (1.8%). Specific IgE to hazelnut was positive in only three patients. DBPCFC was conducted in 11 subjects with a positivity rate of 63.6% (7/11). We observed six mild and one moderate systemic reactions during the DBPCFC. Among seven subjects with a positive DBPCFC, six (85.7%) had a history of hazelnut allergy, and five (71.4%) had both history and skin test positivity.

CONCLUSION

Skin test sensitisation to hazelnut was found to be 1.76% (16/904) which is similar to the sensitisation rate in previous reports. However, DBPCFC was positive in 63% of cases with a history of hazelnut allergy and/or positive skin tests in this study. These results indicate that the presence of history with a positive skin test can be suggestive of hazelnut allergy; however an oral food challenge is needed to confirm the diagnosis.

Prevalence of aspirin-exacerbated respiratory disease in patients with asthma in Turkey: a cross-sectional survey

BACKGROUND

There are no country-based data focused on aspirin (ASA)-exacerbated respiratory disease (AERD) in Turkey.

OBJECTIVE

To assess the prevalence of AERD in adult patients with asthma.

METHODS

A structured questionnaire was administered via face-to-face interview by a specialist in pulmonology/allergy at seven centres across Turkey.

RESULTS

A total of 1344 asthma patients (F/M: 1081/263: 80.5%/19.5%, mean age: 45.7 ± 14.2 years) were enrolled. Atopy rate was 47%. Prevalence of allergic rhinitis, chronic rhinosinusitis/rhinitis, and nasal polyposis (NP) were 49%, 69% and 20%, respectively. Of 270 patients with NP, 171 (63.3%) reported previous nasal polypectomy and 40 (25%) had a history of more than three nasal polypectomies. Aspirin hypersensitivity was diagnosed in 180 (13.6%) asthmatic patients, with a reliable history in 145 (80.5%), and oral ASA provocation test in 35 (19.5%) patients. Clinical presentations of ASA hypersensitivity were respiratory in 76% (n=137), respiratory/cutaneous in 15% (n=27), and systemic in 9% (n=16) of the patients. Multivariate analysis indicated that a family history of ASA hypersensitivity (p: 0.001, OR: 3.746, 95% CI: 1.769-7.929), history of chronic rhinosinusitis/rhinitis (p: 0.025, OR: 1.713, 95% CI: 1.069-2.746) and presence of NP (p<0.001, OR: 7.036, 95% CI: 4.831-10.247) were independent predictors for AERD.

CONCLUSION

This cross-sectional survey showed that AERD is highly prevalent among adult asthmatics and its prevalence seems to be affected by family history of ASA hypersensitivity, history of rhinosinusitis and presence of NP.

Hypersensitivity reactions to contrast media: prevalence, risk factors and the role of skin tests in diagnosis--a cross-sectional survey

BACKGROUND

Hypersensitivity to contrast media (CMs) may be common and serious.

AIM

To evaluate the prevalence of CM hypersensitivity, risk factors associated with it and the role of skin testing in its diagnosis.

METHODS

A structured questionnaire was administered to patients who underwent computed tomography during a 1-year period. Skin tests with CMs, including skin prick tests (SPTs), intradermal tests (IDTs) and patch tests (PTs), were conducted on CM reactors (n = 24). Volunteers who tolerated CM exposure or had never been exposed to any CMs served as controls (n = 37).

RESULTS

A total of 1,131 patients (630 females and 501 males; mean age 55 ± 14.2 years) were enrolled in the study. The prevalence of historical and current CM reactors was 33/1,131 (2.92%) and 8/1,105 (0.72%), respectively. The skin was the most affected site, with mild to moderate reactions. Female gender, a history of doctor-diagnosed asthma, drug allergy, food allergy and psychiatric diseases were significant risk factors. The sensitivities of SPTs and early readings of IDTs in the diagnosis of immediate reactions were 0 and 20%, respectively, and the specificities were 94.6 and 91.4%, respectively. For early readings of IDTs, the positive predictive value (PPV) and negative predictive value (NPV) were 40 and 80%, respectively. For nonimmediate reactions, the sensitivities of delayed readings of IDTs and PTs were 14.3 and 25%, respectively; specificity was 100% for both tests. The PPV was 100% for both of these tests, and the NPVs were 85.4 and 82.4%, respectively.

CONCLUSIONS

Our findings are comparable with the incidence, profile and risk factors associated with CM hypersensitivity reported previously. Skin testing with CMs has a high specificity, but its role in diagnosis is limited due to low sensitivity.

A retrospective analysis of practice patterns in the management of acute asthma attack across Turkey

OBJECTIVE

To evaluate patient characteristics and practice patterns in the management of acute asthma attack at tertiary care centers across Turkey.

METHODS

A total of 294 patients (mean age: 50.4 ± 15.1 years; females: 80.3%) diagnosed with persistent asthma were included in this retrospective study upon their admission to the hospital with an acute asthma attack. Patient demographics, asthma control level, asthma attack severity and the management of the attack were evaluated.

RESULTS

There was no influence of gender on asthma control and attack severity. In 57.5% of the patients, asthma attack was moderate. Most patients (78.9%) were hospitalized with longer duration evident in the severe attack. Spirometry and chest X-Ray were the most frequent tests (85.4%), while steroids (72.0% parenteral; 29.0% oral) and short-acting beta-agonists (SABA) + anticholinergics (45.5%) were the main drugs of choice in the attack management. Attack severity and pre-attack asthma control level was significantly correlated (p < 0.001). Pre-attack asthma was uncontrolled in 42.6% of the patients with severe attack. Most of the patients were on combination of more than one (two in 38.7% and 3-4 in 31.2%) controller drugs before the attack.

CONCLUSION

Providing country specific data on practice patterns in the management of acute asthma attack in a representative cohort in Turkey, prescription of steroids and SABA + anticholinergics as the main drugs of choice was in line with guidelines while the significant relation of pre-attack asthma control to risk/severity of asthma attack and rate/duration of hospitalization seem to be the leading results of the present study.

Genetic aspect of venom allergy: association with HLA class I and class II antigens

Stings from bees and wasps can cause systemic allergic reactions in sensitized patients. However, the mystery of why some cases develop allergic reactions while others do not, remains poorly understood. We investigated whether particular human leukocyte antigen (HLA) class I and class II genes contribute to the development of venom allergy. A total of 21 bee and/or wasp venom sensitive patients who had life-threatening allergic symptoms after a sting, and positive diagnostic tests (Group 1), were included in the study. Thiry-seven healthy subjects without venom allergy (Group 2) were selected as the control group. HLA -class I (A-C) and class II (DR, DQ, DP ) typing was performed by PCR-based techniques. HLA -B*18 and HLA -Cw*07 alleles was found more frequently in Group1 than in Group 2 (14.3 percent vs 2.7 percent, p=0.026, and 31 percent vs 14.9 percent, p=0.036, respectively). Furthermore, HLA -A*01 allele frequency had a trend to be higher in Group 1 than in Group 2 (14.3 percent vs 4.1 percent, p=0.055). However, the frequencies of HLA -A*03 and HLA -Cw*03 alleles were increased in Group 2 compared to Group 1 (20.3 percent vs 7.1 percent, p=0.049 and 10.8 percent vs 0 percent, p=0.024, respectively). Among HLA -class II genotypes, HLA -DQB1*03 allele was significantly increased in Group 2 (60.9 percent vs 38.1 percent, p=0.018), while a higher frequency of HLA -DR B1*03 and HLA -DR B1*14 alleles showed a tendency statistically significant in Group 1 (9.5 percent vs 1.4 percent, p=0.057 and 11.9 percent vs 2.7 percent, p=0.058, respectively). HLA -B*18 and HLA -Cw*07 alleles may probably be associated with susceptibility to venom allergy, whereas HLA -A*03, HLA -Cw*03 and HLA -DQB1*03 seem to be protective markers in a small Turkish population.

Safety of Selective COX‐2 Inhibitors in Aspirin/Nonsteroidal Anti‐inflammatory Drug‐Intolerant Patients: Comparison of Nimesulide, Meloxicam, and Rofecoxib

BACKGROUND

Intolerance to acetylsalicylic acid (ASA) and other nonsteroidal anti-inflammatory drugs (NSAIDs) is a crucial problem in clinical practice. There is, therefore, a need for safer NSAIDs in patients with analgesic intolerance.

OBJECTIVE

To assess the safety of nimesulide, meloxicam, and rofecoxib, selective COX-2 inhibitors, in a group of ASA/NSAIDs-intolerant patients.

METHOD

Tolerances to nimesulide, meloxicam, and rofecoxib were assessed by single-blind placebo-controlled oral challenges. One hundred twenty-seven subjects with history of adverse reaction to ASA/NSAIDs received oral challenges with nimesulide, 61 subjects were challenged with meloxicam, 51 subjects were challenged with rofecoxib, and 37 subjects were challenged with all three drugs. Placebos were given to all patients on the first day of the study. On the second day, one-fourth and three-fourths of the therapeutic doses of the active drugs (nimesulide 100 mg, meloxicam 7.5 mg, or rofecoxib 25 mg) were given at 60-minute intervals. There was at least a 3-day interval between challenge tests. Erythema, pruritus accompanied by erythema, urticaria/angioedema, rhinorrhea, nasal obstruction, sneezing, dyspnea, or cough associated with a decrease of at least 20% in the forced expiratory volume (FEV1) and hypotension were considered as positive reactions.

RESULTS

Positive reactions to the nimesulide, meloxicam, and rofecoxib challenges were observed in 18/127 (14.3%), 5/61 (8.1%), and 1/51 (2.0%) patients, respectively. In each group of nine patients, there were two patients with asthma and four who developed skin type reactions and asthmatic reactions, respectively, to the nimesulide challenge. Among five patients who reacted to the meloxicam challenge, asthmatic type reactions were detected in two asthmatics. Only one urticarial type reaction was observed with rofecoxib challenge in one patient who presented with anaphylaxis to ASA/NSAIDs. All patients with asthma tolerated rofecoxib without any adverse effects. None of the patients reacted to the placebo. Among 37 patients challenged with all three drugs, 11 reacted to nimesulide, and one patient reacted only to meloxicam. Three patients reacted to more than one of the drugs tested, and one of them reacted to all drugs.

CONCLUSION

This is the first placebo-controlled report comparing these three drugs. The results indicate that among these alternative drugs for ASA/NSAIDs-intolerant patients, rofecoxib seems to have the most favorable tolerability.

Triggers in adult asthma: are patients aware of triggers and doing right?

BACKGROUND

As triggers have a potential to induce asthma exacerbations, awareness of the patients to individual triggers as well as protective measures might be helpful to prevent asthma attacks. Though allergens and allergen avoidance have been studied extensively, there are only few studies on non-allergic triggers and their avoidance for adult patients with asthma. In this study, we wanted to investigate asthma triggers and compliance to the preventive measures in an adult population.

METHODS

One hundred and thirty one adult asthma patients were enrolled into the study. A face to face interview was done by using a questionnaire including individual asthma triggers, prevention measures against major modifiable triggers and knowledge sources of the cases.

RESULTS

Regardless of asthma severity, 59.5 % of the subjects reported to be triggered by more than 10 factors. The most common triggers were air pollutants (89.3 %) and weather changes (81.7 %). Severe group was more frequently affected by medications, emotional stress, weather changes and indoor pollutants than other severity groups (p=0.017, 0.014, 0.049 and 0.018, respectively) whereas stress was reported more frequently by females than males. Prevention measures were insufficient regarding some major triggers.

CONCLUSION

Adult patients are vulnerable to several triggers regardless from underlying severity of the illness. Insufficient compliance to the major preventive measures indicates that new strategies are needed to prevent asthma attacks caused by modifiable triggers.

Airway hyperresponsiveness: a comparative study of methacholine and exercise challenges in seasonal allergic rhinitis with or without asthma

BACKGROUND

Asymptomatic airway hyperreactivity in allergic rhinitis is a risk factor for later development of asthma. Although non-specific bronchial hyperresponsiveness (BHR) has been measured by several stimuli, the most appropriate measurement technique still remains unclear.

OBJECTIVE

To investigate whether an exercise challenge can be used to predict BHR in seasonal allergic rhinitis patients with or without asthma and to compare this bronchial reactivity with a methacholine challenge technique.

METHODS

Forty-six consecutive patients with seasonal allergic rhinitis only (n = 31) and with both seasonal allergic rhinitis and asthma (n = 15) were included in the study during the pollination period. Subjects underwent first methacholine (mch) and then exercise challenge testing (ECT). There was a 1-week interval between the tests. ECT was performed on a bicycle ergometer. Positive result was defined as a 15% decrease in forced expiratory volume in 1 second (FEV(1)) post-exercise. A patient's bronchial reactivity to methacholine was considered as hyperresponsive if PC(20) was less than 8 mg/mL.

RESULTS

Mch PC(20) values were significantly lower in patients with both rhinitis and asthma (p < 0.062). Among the 46 patients, mch PC(20) values were significantly different between patients who had positive and negative exercise challenge tests (p = 0.007). All patients with rhinitis alone had a negative ECT and 10 had a positive mch challenge. Change in FEV(1) values after ECT was significantly higher in patients with both rhinitis and asthma compared to those with rhinitis alone (p = 0.009). There was a significant relation between positivity of mch and exercise challenges (p = 0.025). ECT positivity was found to be a significant confounding factor in the diagnosis of asthma (p = 0.001). Specificity and sensitivity values were 100% and 24% for ECT and 68% and 100% for mch, respectively.

CONCLUSION

Exercise challenge presents poor diagnostic value for detecting bronchial responsiveness in individuals with allergic rhinitis alone during the pollen season.

Is there any difference in the use of complementary and alternative therapies in patients asthma and COPD? A cross-sectional survey

BACKGROUND

Data on the use and efficacy of complementary and alternative medicine (CAM) in patients with asthma are limited, and there is a lack of studies documenting the use of CAM in patients with chronic obstructive pulmonary disease (COPD) in Turkey.

AIM

To determine the prevalence of CAM usage in patients with asthma and COPD and to assess the clinical and demographic factors associated with the use of CAM.

MATERIALS AND METHODS

A total of 521 patients (313 with asthma and 208 with COPD) were randomly enrolled into this cross-sectional survey. A face-to-face interview was conducted using a structured questionnaire.

RESULTS

One hundred sixty-three patients (52%) with asthma and 70 patients (33%) with COPD were reported to be using some form of CAM (p < 0.001). The most popular modalities were herbal remedies (46% and 28% in the two groups, respectively) and animal products (28% and 5% in the two groups, respectively). CAM-practicing asthma patients were typically younger with longer duration of disease and higher income than the CAM-practicing COPD patients. For the patients, the main source of information on CAM practices was their relatives and friends. Only a small number of the patients consulted with their physicians about CAM. The main reasons to use CAM for patients with asthma and COPD were harmlessness and symptomatic relief, respectively. CAM-related adverse effects and difficulties to obtain CAM were significantly higher in patients with asthma than in patients with COPD.

CONCLUSION

There is a high prevalence of CAM usage in patients with asthma and COPD in Turkey. Hence, becoming familiar with CAM therapy and inquiring about patient practice of CAM as part of the routine medical history will allow the physicians to provide reliable information to their patients on these medical practices.

Regional pollen load: effect on sensitisation and clinical presentation of seasonal allergic rhinitis in patients living in Ankara, Turkey

BACKGROUND

Although Gramineae pollens are the main reason for seasonal allergy in many parts of Europe, the influence of regional flora on sensitisation and symptoms has always been a topic of interest. The aim of this study was to document the sensitisation to pollens and to evaluate their clinical importance in patients with seasonal allergic rhinitis living in Ankara/central Anatolia.

METHODS

The study included those subjects with seasonal allergic rhinitis living in Ankara. Skin prick testing with a panel of common aeroallergens as well as grass, individual tree and weed pollens predominant in the region was performed. The patients were followed by symptom-medication scores during the same season in which regional pollens were also counted.

RESULTS

The final eligible study consisted of 54 subjects (F/M: 26/28; mean age: 29.4 years). Trees were the most common pollen source consisting of 95 % of the total amount, followed by grasses (3 %) and weeds (2 %). Sensitisation to Gramineae, to at least one weed; and to tree pollens were 100 %, 85.2 % and 94.4 %, respectively. The most common positive skin tests among tree pollens were to Oleaceae (59.2 %), Aesculus (57.4 %); and Tilia (42.5 %) despite low pollen counts. Chenopodiaceae (88 %) and Plantago (63 %) were the most sensitised weed pollens, with high pollen counts. All patients had significant symptoms during May and June.

CONCLUSION

Although Gramineae pollens seem to be major allergens for seasonal allergic rhinitis in Ankara, the particular role of tree pollens and weed pollens cannot be discarded on symptom development in sensitised patients.

Cellular allergen stimulation test with acetylsalicylic acid-lysine is not a useful test to discriminate between asthmatic patients with and without acetylsalicylic acid sensitivity

BACKGROUND

The aspirin provocation test, considered to be the gold standard in the diagnosis of aspirin sensitivity, may be associated with severe adverse reactions; thus, alternative procedures with a higher safety profile are highly desirable. Although the cellular antigen stimulation test (CAST) has been proposed to be such an alternative, there is limited information about its clinical usefulness.

OBJECTIVE

It was the aim of our study to evaluate the clinical usefulness of CAST in the diagnosis of aspirin sensitivity.

MATERIAL AND METHODS

Patients with aspirin-sensitive asthma and/or nasal polyps (n = 40), patients with aspirin-tolerant asthma and/or nasal polyps (n = 13) and healthy volunteers (n = 26) were included. A 2-day, single-blind placebo-controlled oral aspirin provocation test was performed. In vitro release of cysteinyl leukotrienes (Cys-LTs) by peripheral blood leukocytes was measured after stimulation with both stimulation buffer and lysine aspirin (2.5 mg/ml) by CAST.

RESULTS

Baseline Cys-LT levels were similar among the 3 groups. After lysine aspirin stimulation, the net increase in Cys-LTs was significantly higher in patients with aspirin sensitivity (median 91 pg/ml, interquartile range 22-206) compared with aspirin-tolerant patients (20 pg/ml, range 0-46) and healthy controls (23 pg/ml, range 0-71; p = 0.004). The assay had a sensitivity of 25%, a specificity of 92.3%, and positive and negative predictive values of 28.7 and 90.7%, respectively.

CONCLUSION

Although the leukocytes of patients with aspirin sensitivity produce higher amounts of Cys-LTs as measured by CAST, the low sensitivity and predictive values limit the clinical usefulness of this test in the diagnosis of aspirin sensitivity.

A breath for health: an exploratory study in severe asthma patients in Turkey

BACKGROUND

Severe asthma puts enormous burden on patients. To evaluate asthma-related restrictions on patients' daily lives along with their expectations about future asthma care.

METHODS

A structured questionnaire was administered to severe asthma patients at 25 centers across Turkey. The patients were divided into; uncontrolled (n: 274) and controlled asthma (n: 177) according to the existence of symptoms despite the GINA step 4 or 5 treatment.

RESULTS

A total of 451 patients (F/M: 337/114, mean age: 47.6 +/- 13.2 years) were included; 93% were nonsmokers and 51.2% were atopic. Chronic rhino-sinusitis, ASA/NSAID sensitivity, and osteoporosis were significantly higher in uncontrolled patients. Nearly 70% of the uncontrolled asthmatics defined asthma as disturbing with significant restrictions in daily life. The most important role for medication was symptom relief. One inhaler or one tablet a month was the most preferred form of drug usage. In addition, 30.6% of the patients had tried alternative treatment with herbal remedies. Although patients were willing to become members of an asthma association, they expected the Turkish government to provide special asthma clinics and fund research into new treatments. Controlled patients achieved or were close to achieving asthma control goals. Uncontrolled patients seemed to be more pessimistic in this respect, but they reserved significant levels of hope for the future. Two-thirds of all the patients thought that they would receive better treatment in the next 5 years.

CONCLUSIONS

In this study group, severe asthma patients face significant limitations in their daily lives, but they are optimistic about better asthma control and treatment options in the future.

Leukotriene receptor antagonists: a good choice in the treatment of premenstrual asthma?

The aim of this study was to investigate the effects of leukotriene receptor antagonists (LTRAs) on the premenstrual exacerbation of asthma (PMA). Twenty-four female patients with mild asthma were enrolled in the study. Patients were followed for three menstrual cycles and separated into two groups based on whether they exhibit premenstrual worsening of asthma symptoms (n = 11) or not (n = 13). During the first month all were treated with only inhaled steroids (IS) (run-in period); during the second month they received IS plus placebo; and during the third month they were given IS plus montelukast. Furthermore, they were advised to use beta(2)-agonists as needed. Peak expiratory flow rate (PEFR) and symptom scores were recorded during the 3 months. Pulmonary function tests (PFT) and the levels of oestrogen, progesterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were measured a week before the beginning of the menstrual period. At the end of the 3-month period, it was observed that following therapy with montelukast, the patients with PMA showed significant improvement in PEFR variability and symptom scores when compared with the placebo group. Baseline FSH levels were higher, but FSH and other hormone levels and PFTs did not change in these groups. However, in the group without PMA there was no difference between the montelukast or placebo groups in PEFR variability, symptom scores, PFTs, and hormone levels. Based on the data in hand, it could be stated that LTRAs have ensured the control of symptoms and improved PEFR variability in patients with PMA by suppressing inflammation. We are of the view that LTRAs would be a right choice in the treatment of patients with PMA.

Lipoxin A4 levels in asthma: relation with disease severity and aspirin sensitivity

BACKGROUND

Lipoxin (LX) A4, an endogenous anti-inflammatory eicosanoid, has been found to be low in patients with severe asthma. However, few studies also suggested more diminished LX A4 levels in aspirin-exacerbated respiratory disease (AERD) when compared with aspirin-tolerant asthma (ATA). It is, therefore, currently not clear whether the asthma severity or the presence of AERD has a primary role in the disturbed LX metabolism.

OBJECTIVE

To detect LX A4 and 15-epi-LX A4 levels in asthma patients with and without AERD of comparable severity.

METHODS

The study groups consisted of 22 subjects with AERD, 22 subjects with ATA and 10 volunteers without asthma and aspirin sensitivity. Whole-blood samples were stimulated with calcium ionophore, A23187 (5 x 10(-5) m) and A23187 (5 x 10(-5) m)+aspirin (10(-4) m). LX A4 and 15-epi-LX A4 levels were analysed by the enzyme immune assay method.

RESULTS

Severe asthma patients in both AERD [0.5 (0.8)] ng/mL and ATA [0.5 (0.45) ng/mL] groups showed diminished generation for LX A4 to stimulation with A23187 in comparison with other severity degrees in their groups (P=0.02 and 0.046, respectively). LX A4 generation in both severe groups was comparable with each other (P>0.05). Although severe cases with AERD showed a diminished capacity to generate 15-epi-LX A4, this did not reach statistical significance.

CONCLUSION

This study indicated that diminished LX A4 generation was unique to severe asthma phenotype regardless of comorbid aspirin sensitivity. Clinical Implications Lower LX A4 levels in severe asthma would suggest a possibility for LX analogues as future treatment options in these patients.

[Allergic bronchopulmonary aspergillosis: 3 cases]

Allergic bronchopulmonary aspergillosis (ABPA) occurs in approximately 1-7.6% of patients with asthma. This incidence is low enough not to be considered in the differential diagnosis but also high enough to be an important disease. Since the symptoms and laboratory tests are not specific for ABPA, the diagnosis may be delay for years. However the failure to diagnose and treat ABPA for long term may result in fibrotic lung disease. This article focuses on the clinical and the laboratory aspects, and the management of ABPA in the light of three cases.

Dipyrone improves small airway function in asthmatic patients with moderate obstruction

BACKGROUND

Dipyrone is an analgesic and antipyretic agent with a distinctive spasmolytic effect on smooth muscles. We recently showed that dipyrone significantly relaxed precontracted tracheal smooth muscle in guinea pig.

OBJECTIVE

To investigate whether this in vitro observation could be observed in vivo in the respiratory function parameters of asthma patients.

METHOD

Twenty-two patients, aged 18 to 75 years and diagnosed with asthma according to the American Thoracic Society criteria were enrolled at the time they had any indication for dipyrone use. Pulmonary function tests were performed before and 30, 60, 90, and 120 minutes after oral intake of 1 g of dipyrone. The tests were repeated without dipyrone intake in a situation of spontaneous recovery after a minimum washout period of 2 days.

RESULTS

Patients were classified according to their baseline forced expiratory volume in 1 second (FEV1) as having mild obstruction (FEV > or =80% predicted) or moderate obstruction (FEV1 60%-80% predicted). Significant improvement with dipyrone was seen in FEV1 and peak expiratory flow rates at 25%, 50% and 75%) of forced vital capacity and in maximum midexpiratory flow rate only in patients with moderate asthma. No significant change was observed on the spontaneous recovery day except in FEV1.

CONCLUSION

Dipyrone had a significant effect leading to an improved small airway function in asthmatic patients with moderate airway obstruction, confirming our recent in vitro findings.

Fasting: an important issue in asthma management compliance

BACKGROUND

Fasting, neither eating nor drinking anything between dawn (sahur time) and sundown (iftar time), may have an important role in the treatment and follow-up of asthmatic patients in countries where most of the population is Muslim.

OBJECTIVE

To analyze the effects of fasting on outpatient asthmatic patients.

METHODS

One hundred twenty-one fasting patients were evaluated for attendance at follow-up visits, attitudes about undergoing diagnostic investigations, and opinions and practices regarding medication use during fasting. Their sources of knowledge about asthma, fasting, and medication consumption were also evaluated.

RESULTS

Ninety percent of fasting patients reported no harm with respect to religion of visiting physicians while fasting. Although 96% of the patients stated that inhaled medication could be used, only 13% continued to use medication in the same manner as when they were not fasting. Most patients rearranged their medication-consumption hours. Although 96% of the patients received general information about asthma from their physicians, rates of receiving information about the fasting-medication use relationship from physicians and religious sources were similar (37% and 32%, respectively).

CONCLUSION

Most Muslim asthmatic patients do not consider asthma to be a drawback to fasting, and they continue fasting by rearranging their medication consumption times. During Ramadan, patients should be questioned about this subject and should be followed up carefully for asthma control at regular visits.

Psychological status of patients with chronic urticaria

Although chronic urticaria is the most common cutaneous disorder seen in our outpatient allergy clinics, to our knowledge, no study of psychiatric morbidity in allergy departments has been carried out in our country. For the present study, we used the Minnesota Multiphasic Personality Inventory (MMPI) to evaluate the personality traits and psychological status of patients with chronic idiopathic urticaria (CIU). Fifty-nine outpatients with CIU and 59 healthy control subjects were enrolled in the study. Patients were included if no specific cause for their urticaria could be identified by detailed history and appropriate investigations. Psychiatric evaluation for all patients and controls was conducted at the Department of Psychiatry by using MMPI. Analysis of the MMPI profile showed that the scores for hypochondriasis, depression, hysteria, psychopathic deviance, paranoia, psychasthenia, schizophrenia, and social introversion were higher in patients with CIU compared to the control group (P < 0.05). The mean score of hysteria was significantly higher in women. There were no significant correlations between the scores of MMPI and duration of the disease. These data indicate that our patients with CIU seem to have more depressive, hysteric, touchy and suspicious personality traits with hypochondriac tendencies and in more conflict with their social environment. Attitudes such as perfectionism, need for approval, external control and need to be loved were also characteristics of the patient group. We believe that psychological status should be considered for effective management of patients with CIU.

Clinical aspects of the link between chronic sinonasal diseases and asthma

Chronic sinonasal diseases (CSDs) are common comorbidity of asthma. The aim of this study was to assess comprehensively CSD in a population of asthma patients and determine whether the clinical factors in both diseases were related to each other. Eighty adult stable asthmatic patients with sinonasal symptoms (SNSs) of 3 months and who were nonresponsive to aggressive medical treatment were prospectively investigated. All patients underwent a detailed ear, nose, and throat examination and were evaluated by paranasal sinus computed tomography (PNS-CT). The severity of asthma was compared with SNS scores (SNSSs) and sinonasal involvement on PNS-CT. Asthma was severe in 12.5%, moderate in 55%, and mild in 32.5% of cases. There were 15 (18.7%) patients in stage 0, 16 (20%) patients in stage 1, 21 (26.2%) patients in stage 2, and 28 (35%) patients in stage 3 according to PNS-CT scoring. There was no correlation between asthma severity and CT stages, total opacification scores (TOSs), anatomic variations, and SNSSs. Although SNSSs were similar in patients with nasal polyps (NPs) and without NPs, patients with NPs showed significantly higher TOSs and CT stages (p < 0.05). The presence of NPs and age and duration of disease were related to severity of asthma (p < 0.05). Nonatopic asthmatic patients had both more severe asthma (p = 0.05) and more extensive CT findings (p = 0.01). The use of clinical symptoms alone is not very reliable in predicting the presence or severity of CSD. Therefore, SNSs should be supported with objective criteria such as nasal endoscopy and PNS-CT scan. Furthermore, sinonasal involvement may exist independently from severity of asthma.

Safety of meloxicam in aspirin-hypersensitive patients with asthma and/or nasal polyps. A challenge-proven study

BACKGROUND

The anti-inflammatory actions of acetylsalicylic acid (ASA)/non-steroidal anti-inflammatory drugs (NSAIDs) are thought to be due to inhibition of COX-2, whereas the side effects such as gastric damage and aspirin-induced asthma are mediated through inhibition of COX-1. Therefore, a new class of drugs with COX-2 selectivity may be well tolerated by patients with ASA/NSAIDs hypersensitivity.

OBJECTIVE

We investigated whether subjects with asthma and/or nasal polyps (NP) and analgesic intolerance proven by oral ASA provocation test tolerated the selective COX-2 inhibitor, meloxicam.

METHODS

All subjects were first challenged with ASA using a 2-day, single-blind, placebo-controlled oral provocation test. Thereafter, the subjects showing positive response to ASA provocation underwent a single-blind, placebo-controlled challenge with a cumulative dose of 7.5 mg of meloxicam on 2 separate days. One and three fourths of the divided doses of placebo and the active drug were given at 1-hour intervals. Clinical symptoms, lung function, and blood pressure were monitored during these challenge protocols.

RESULTS

Twenty-one patients with asthma and/or NP (10 males and 11 females; mean age: 38.4 +/- 2.9 years) who reacted to ASA challenges were enrolled in the study. Response to ASA provocation was rhinitis + bronchospasm in 13, and extrabronchial reactions in 8 (isolated rhinitis in 3) patients. Mean PD(20) was 163.4 +/- 39.9 mg ASA among patients who reacted with bronchospasm to ASA. Only 1 patient reacted to meloxicam challenge at a cumulative dose of 7.5 mg.

CONCLUSION

This study indicates that 7.5 mg of meloxicam is a safe alternative treatment for ASA-hypersensitive asthma and/or NP patients with proven hypersensitivity via oral ASA challenges.

Sensitization to Alternaria and Cladosporium in patients with respiratory allergy and outdoor counts of mold spores in Ankara atmosphere, Turkey

Sensitization to Alternaria and Cladosporium has been reported to be 3% to 30% in European countries. However, in Turkey, there is limited data about the prevalence of sensitization to these molds and the intensity of the two mold spores in Ankara atmosphere. This study was designed to evaluate the sensitization to Alternaria and Cladosporium in patients with respiratory allergy in Ankara and also the concentration of the two molds in Ankara atmosphere. Allergic rhinitis and asthma patients living in Ankara were included in the study. Demographic and diagnostic data of the patients were recorded. A skin prick test with extracts supplied by three different laboratories was used to evaluate the sensitization to Alternaria and Cladosporium. Mold spores were measured using a Burkard 7-day recording volumetric spore trap in Ankara atmosphere during a year. Overall sensitization to the two molds was found to be 14.8%, and isolated Alternaria or Cladosporiumsensitization was 3%. Considering the positive reaction to at least one of the three suppliers, the sensitization rate was 11.9% and 8.1% for Alternaria and Cladosporium, respectively. Cochran's Q homogenization test demonstrated that the positive and negative reaction were not homogeneous among three laboratories. The total number of mold spores in Ankara atmosphere was 429,264 spores/m3 of which 75.5% and 6% were constituted by Cladosporium and Alternaria, respectively. The prevalence of Cladosporium and Alternaria sensitization in respiratory allergy patients is quite similar to European countries; however, our data indicate that commercial mold extracts should be standardized to establish the real sensitization rates. Additionally, considering the great numbers of these mold spores in Ankara atmosphere, long-term follow-up studies are needed to evaluate the relationship between the mold load and sensitization patterns.

Does the combination of inhaled steroids with long acting beta2 agonists decrease the risk for osteoporosis? A 1-year prospective follow-up study

Combination of inhaled corticosteroids (ICS) with long acting beta2 agonists has been used increasingly in the treatment of moderate-severe asthma, however there is indefinitive data about their effect on bone loss. The aim of this study was to compare the effects of treatment with single ICS and combination of ICS with long acting beta2 agonists (combination therapy) on BMD and biomarkers of bone metabolism in adult patients with asthma over 1 year period. Forty-three patients with asthma were enrolled. Patients were separated into two groups according to their use of asthma drugs: single ICS or combination therapy (ICS plus long-acting inhaled beta2-agonist). Change in bone mineral density (BMD) and biochemical markers of bone metabolism were measured at baseline and at the end of 1 year. Mean ages and basal BMD of patients did not differ between the two groups (P > 0.05). The decrease in BMD was higher in the single ICS group than the combination therapy group, however there was no significant difference between them (P > 0.05). One year change (%) in BMD and biochemical markers of bone metabolism were not different between two groups (P > 0.05). In conclusion, use of ICS-in the range of doses used- does not seem to have an effect on the change of BMD. However, our data indicate a nonsignificant trend towards reducing bone loss with the use of combination therapy. Future studies are needed to provide definitive evidence for this trend to allow us suggesting combination therapy for minimizing bone loss.

Pigeon breeder's lung in childhood: is family screening necessary?

In this paper, we report on clinical and laboratory findings of pigeon breeder's lung (PBL) in a mother and her 2 children: 2 with the chronic recurrent form, and 1 with the chronic insidious form without any symptoms or signs, who was diagnosed during family screening. The index case was diagnosed as having primary pulmonary hypertension on admission. However, on evaluation, the diagnosis was of pigeon breeder's lung in the index case and her symptomatic mother. High-resolution computerized tomography (HRCT) revealed interstitial lung disease in an asymptomatic sister of the index case. All cases responded to steroid treatment, and at the end of the third month, HRCT findings disappeared. In conclusion, in patients with acute respiratory symptoms and rapidly recovering pulmonary hypertension after hospitalization, PBL should be remembered. All family members of the index case should be screened by HRCT in terms of interstitial lung disease, even if they are asymptomatic.

Differences between asthma and COPD in the elderly

Asthma and chronic obstructive pulmonary disease (COPD) are both characterized by the presence of airflow obstruction. Both diseases are not rare in the elderly population. Distinguishing between these diseases is difficult and may be impossible in some older patients. The aim of the study was to investigate clinical and functional characteristics and the presence of atopic status in elderly subjects compared to COPD patients. Fifty-one patients over 60 years of age were selected for the study (27 patients with late-onset asthma, 24 patients with COPD). Atopy was defined by skin prick test and serum total IgE concentrations which were measured in all patients. Pulmonary function tests including airflow rates, lung volumes, airway resistance, diffusing capacity, and arterial blood gases analysis were performed in all patients. The rate of skin prick test positivity in asthmatics was significantly higher than that of the COPD patients. FEV1 was lower in COPD patients than in asthmatic patients. Bronchial reversibility in asthmatics became significantly higher than in COPD patients. While FRC and RV were increased in both groups showing same degree of pulmonary hyperinflation, patients with COPD demonstrated significantly decreased DLCO when compared to asthmatic patients. The level of both PO2 and PCO2 in patients with COPD significantly differed from asthmatics. In conclusion, a history of heavy smoking, decreased diffusing capacity for carbon monoxide, the presence of more prominent lung hyperinflation and chronic hypoxemia favour the diagnosis of COPD, whereas atopy and significant bronchodilator responsiveness favour the diagnosis of asthma.

The safety of allergen immunotherapy (IT) in Turkey

Allergen immunotherapy (IT) has encouraging therapeutic outcomes but its safety is still being questioned because of possible severe systemic reactions. The aim of this study was to determine the frequency of systemic reactions (SR), and to identify their correlation with the characteristics of therapy, such as allergen composition and IT schedule, and diagnosis. We analyzed the data of 126 patients who received IT between 2000-2003, and suffered from respiratory allergy or hymenoptera venom anaphylaxis. IT was given by rush, clustered or conventional schedules. The standardized allergen extracts used were grass pollen, house dust mite and hymenoptera venom in 88, 18 and 20 patients, respectively. None of the patients received premedication. A total 4705 injections were administered. One hundred and twenty-three adverse events (AE) (2.6% per injection) were documented in 46 patients. Sixty-one of them were SRs (1.3% SRs per injection) and they were seen in 28 patients. Asthmatics had more tendency to SRs (p=0.05). Rush (1.8%) and clustered (2.8%) IT protocols were associated with a higher rate of SRs (per injection) when compared to conventional schedule (0.9%) (rush vs conventional; p=0.013, clustered vs conventional; p=0.001). The majority of SRs corresponded to grade 3 (49%). Forty-nine (80%) of the 61 SRs were observed during the build-up phase, and mostly with pollen extracts (75.5%). Patients showed more severe SRs during the build-up phase (p<0.05). Twenty-six (42.6%) of the SRs were immediate, whereas 35 (57.4%) SRs appeared within 2 hours. Delayed SRs were significantly more frequent in polysensitized patients when compared to monosensitized subjects (p=0.018). Our data indicate that rapid IT regimens and the presence of asthma represent a greater risk for SR development. Since the late SRs occur as frequently as the early ones, we suggest a longer waiting period beyond 30 minutes, especially in polysensitized and asthmatic patients.

Meloxicam-associated anaphylactic reaction

Anaphylactic reaction to meloxicam has never been reported to date. We report 2 cases of meloxicam-induced anaphylactic reaction with no sensitivity to another selective cyclooxygenase 2 inhibitor. A thorough drug allergy work-up should be done before other cyclooxygenase inhibitors are prescribed.

Rush hymenoptera venom immunotherapy is efficacious and safe

BACKGROUND

Although rapid venom immunotherapy (VIT) protocols have been shown to be safe and effective, this issue has not yet been clarified in Turkey.

OBJECTIVE

The aim of this study was to evaluate the side effects of rush VIT as well as early clinical and immunological responses in patients with a venom allergy.

METHODS

Eighteen patients who had a history of severe systemic reactions after Hymenoptera sting were included in the study. The diagnosis was made on the basis of positive skin test reactivity and the presence of specific IgE in serum to either bee or vespid venoms. Fourteen patients underwent an average 7-day rush VIT regimen under careful monitoring in our clinic. Among them 7 patients were treated with Vespula species and 7 with Apis mellifera venom extracts. Four patients were followed up as a control group. Skin test response, specific IgE and IgG4 levels were determined before and after a year of VIT. Local and systemic reactions due to injections were monitored during the induction and maintenance phases of VIT.

RESULTS

Specific IgG4 levels significantly increased after 1 year compared with levels before VIT (mean concentration before and after; 13.04 vs 21.85 mg/L, respectively; P < .05) whereas specific IgE levels did not change (11.54 vs. 13.32 kU/L). No significant differences were observed before and after one year of VIT in skin prick (2.34 vs 3.66 mm) and intradermal (0.12-0.11 microg/mL) test reactivities (P > .05). A single patient treated with bee venom developed 4 mild systemic reactions (4/469 injections, 0.85%) during the course of VIT. More local reactions occurred in patients receiving bee venom extract (3.33%) than in those receiving yellow jacket venom (1.33%). Two patients tolerated field stings without reactions.

CONCLUSION

Our experience confirms that rush VIT is safe and has a low systemic reaction. It can be considered for patients requiring rapid protection.

Rofecoxib, as a safe alternative for acetyl salicylic acid/nonsteroidal anti-inflammatory drug-intolerant patients

BACKGROUND

Intolerance to acetylsalicylic acid (ASA) and nonsteroidal anti-inflammatory drugs (NSAIDs) is a crucial problem in medical practice. There is therefore a need for safer NSAIDs in analgesic-intolerant patients.

OBJECTIVE

To assess the safety of rofecoxib, a selective COX-2 inhibitor, in ASA/NSAID-intolerant patients.

METHODS

A single blind, placebo-controlled oral challenge procedure was applied to 94 adult patients (M/F: 30/64, mean age: 39.2 +/- 11.9 yrs) with a reliable history of ASA/NSAID intolerance. 1/4 and 3/4 divided doses of placebo and rofecoxib were given with 2-hour intervals on consecutive days. During the challenge procedure, blood pressure, heart rate, nasoocular, pulmonary and cutaneous symptoms were monitored. Erythema, pruritus accompanied by erythema, urticaria/angioedema, rhinorrea, nasal obstruction, sneezing, dyspnea or cough associated with a decrease of at least 20% in the FEV1, and hypotension were considered as positive reactions.

RESULTS

None of the patients reacted to placebo. Only one patient (1.1%) presented urticarial-type cutaneous reaction to rofecoxib challenge. The remaining patients (98.9%) perfectly tolerated the drug challenge.

CONCLUSION

Rofecoxib can be used as a safe alternative drug for ASA/NSAID intolerant patients.

Allergy to drugs: is there an association with mental ill-health?

Objectives. Hypersensitivity reactions to drugs are not infrequent. A certain of anxiety, aggression or depression should be expected in patients with drug allergies, as they could experience symptoms ranging from mild to life-threatening reactions following consumption of drug. However, a literature search resulted in very limited data. This study was designed to evaluate the psychological status of patients with drug allergy and to assess the relationships between psychological evaluations of the patients and, duration of drug allergy, type of allergic reaction, hypersensitivity reaction of the type of drug involved. Methods. The study group comprised 61 patients (43 F, 18 M), age ranging from 16 to 75 years, with reliable history of drug allergy. A total of 55 healthy subjects (39F, 16M) age ranging from 17 to 70 years served as control group. Assessment tools consisted of Beck Depression Inventory (BDI), and Speilberger's State-Trait Anxiety Inventory (STAI Tx-2). Results. The prevalence of depression and anxiety among patients with drug allergies was not greater than that of the controls. There were no associations between the scores of these psychological assessments and duration of drug allergy, type of allergic reaction, type of drug. Conclusions. Our data suggest that follow-up studies including high numbers of patients and patients with specific and potentially life-threatening clinical pictures of drug allergies are needed to detect clinically relevant associations.